The use of Section 136 (Mental Health Act 1983) in Gloucestershire

Med Sci Law 2010;50:29-33
doi:10.1258/msl.2009.009017
© 2010 British Academy of Forensic Science

 

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The use of Section 136 (Mental Health Act 1983) in Gloucestershire

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J Laidlaw MRCPsych * ,
D Pugh CQSW MBA ,
G Riley BSc MSc  and
N Hovey BSc (Hons) 


* Consultant Psychiatrist, 2gether NHS Foundation Trust, Montpellier Unit, Horton Road, Gloucester GL1 3WL, UK
Mental Health Act Implementation Manager, Gloucestershire Primary Care NHS Trust and Gloucestershire County Council, UK
Research Assistant
Audit Manager, 2gether NHS Foundation Trust, Montpellier Unit, Horton Road, Gloucester GL1 3WL, UK

Correspondence: Dr J Laidlaw. Email: jim.laidlaw{at}glos.nhs.uk




Abstract

TOP

Abstract
Introduction

Method

Results

Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

The small number of published studies on the use of Section136 (S136) of the Mental Health Act 1983 may reflect neitherthe current situation nor the true national picture as mostof the research comes from large urban centres and was publishedbefore 1997. We studied the use of S136 between 2002 and 2006in Gloucestershire, a rural English county with a populationof approximately 585,000, by analysing data held by the policeand local mental health services. On average 192 subjects (range176–203) were detained each year under S136, equatingto a population rate of 32.8 S136 detentions per 100,000 peryear in Gloucestershire. In contrast to other published studies,ethnic minorities, particularly Afro-Caribbean males, were over-representedonly in a minor way. Of those individuals detained, about athird were admitted, a lower rate than in other studies. Actsor threats of self-harm were common (55%), but acts or threatsof violence (28%) and evidence of intoxication (16%) were presentin a minority, suggesting that detainees are more likely topose a risk to themselves than others.





Introduction

TOP

Abstract

Introduction
Method

Results

Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

In England and Wales, Section 136 (S136) of the Mental Health Act 19831 gives a police constable the power to detain an individual that they find to be mentally disordered in a public place and in need of care and control. The individual is conveyed to a Place of Safety (POS) to allow for further assessment. Thus, for example, a dishevelled and thought-disordered man who is shouting about persecutory delusions and wandering in front of traffic on a public road might be detained by a police officer under S136 and taken to a POS for further assessment. The nature of the POS varies from area to area but is typically either the police cells, a psychiatric hospital or sometimes an emergency department in a general hospital. Usually the police officer will have considered less restrictive options for managing the situation before using S136. As an alternative, if an offence has been committed, the individual might be arrested and taken to the cells where an assessment under the MHA1 could subsequentlybe organized, outwith the provisions of S136.

There is a paucity of research on S136. Most of it emanates from large urban centres in England,25 and most of the research was published before 1997. Exceptions are the review conducted by a working party of the Royal College of Psychiatrists,6 which led to the setting of new guidelines for the use of S136 in England7 and the recently published Independent Police Complaints Commission (IPCC) report into the use of police cells as a POS.8 This latter study considered only the use of police cells rather than other POSs and therefore the published research, taken as a whole, may reflect neither the current situation nor the complete national picture.6 Although professionals’ knowledge of details of S136 law have been studied,9 littleis known about how S136 is used in practice.

Official Department of Health (DoH) statistics are limited to S136 detentions where a hospital is used as a POS and fail to capture the situations where police cells are used. The IPCC study,8 using police data, provided useful information regarding use of police cells as a POS. However, having two separate sources of national data covering the use of the POS is problematic for monitoring and research purposes. This difficulty in obtaining reliable data on the use of S136 has been noted elsewhere.6

The current Code of Practice for the MHA 198310 states that police cells should only be used as a POS on an ‘exceptional basis’ in S136. While hospital settings are increasingly being used, a study in 2005 showed that 34% of localities used police cells exclusively as a POS.11 The IPCC study8 compared police and DoH data, showing that two-thirds of S136 detainees were held in police cells with only a third being taken to a hospital POS. Thus the use of police cells as a POS is far from ‘exceptional’. National policy supports the development of alternatives to using police cells as a POS and £130 million for this purpose has been made available from the DoH to mental health services. The Royal College of Psychiatrists recently published updated guidance on standards for the use of S136.7

To advance knowledge and inform the development of local practice,we studied the use of S136 between 2002 and 2006 in Gloucestershire,a rural English county with a population of approximately 585,000.





Method

TOP

Abstract

Introduction

Method
Results

Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

This study was part of a larger research project into S136 whichincluded investigating the attitudes and beliefs of professionalsinvolved in the detention process and also the experience andviews of S136 detainees and their carers. Favourable opinionfor the research was obtained from the local research ethicscommittee and the mental health trust research governance committee.The methodology was a retrospective analysis of data collectedas part of routine monitoring of S136 activity in Gloucestershire.

Two data sources were used. First, data were obtained from thepolice (Gloucestershire Constabulary) computer systems for thethree years 2003–2006. These data are routinely collectedby the police when individuals are booked in after arrivingat the police cells. Before being supplied to the researchers,the data were anonymized and collated by police staff. Secondly,we had access to data from a paper-based monitoring system onS136 activity held by 2gether NHS Foundation Trust (providerof specialist mental health services) during the period 2002–2004(1 year 10 months). The Trust Audit Department anonymized andcollated the data before they were made available to the researchers.

Data from both sources were entered onto a software package(Microsoft Excel) on a password-protected computer in a lockedoffice in Trust premises. Analysis was by Microsoft Excel andStatistical Package for Social Sciences (SPSS).





Results

TOP

Abstract

Introduction

Method

Results
Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

Results are shown in Tables 13. For ease of comparison we have, where possible, placed results from the two data sources side by side. Table 1 shows numbers detained and demographics; Table 2 the circumstances of detention; and Table 3 the outcomes of assessment.



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Table 1 Numbers detained under S136 and their demographic characteristics



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Table 2 Circumstances of detention under S136



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Table 3 Outcome of S136 assessment


Police data

In the three years studied, a mean of 192 subjects (range 176–203)were detained each year under S136. This equates to a mean rateof 32.8 S136 detentions per 100,000 per year in Gloucestershire.

People subject to S136 detention were 61% men. The commonest age range for detainees (33%) was 35–44 years, the range being from under 18 years to over 65 years. The ethnic mix of detainees was broadly in keeping with the ethnic mix of Gloucestershire residents: 93% were white, 3% black, 1% Asian, the rest being ‘other’ or ‘unknown’. The 2001 Census showed Gloucestershire’s non-white ethnic minority population (2.8%) to be below the national average.12

Detentions were distributed fairly evenly through the week butwith a slight trough midweek on Wednesdays. The busiest timeof day for S136 detentions was 18:00 hours to midnight (34%),with the quietest time being 06:00 hours to midday (14%). Detentionswere fairly evenly distributed throughout the year, with a slightdip in the first quarter (January to March).

Just over a third (34%) of the detainees were admitted to hospital.Of those not admitted, the vast majority (95%) left the cellswith no further action. A minority (5%) were subject to furtherpolice action such as being charged or cautioned, or being detainedunder outstanding warrants.


Mental health services data

This data set comprised paper monitoring forms completed over22 consecutive months between 2002 and 2004. These forms werecompleted by the police involved in the detention of each individualalong with the Approved Social Worker and/or doctor (usuallya senior psychiatrist) who undertook the assessment of the detainee.The monitoring forms collected a combination of demographicand clinical details.

These forms recorded 186 detentions over the 22 months, a meanof 101 detentions per year. The mean age of detainees was 37years (range 14–91); 55% were male. The ethnicity of detaineeswas: 95% white, 3% black and 2% other or unknown; 8% of detaineescame from addresses outside the county and 5% had no fixed abodeor no known address. Repeated detentions were evident, as 9%of detainees had been detained under S136 on at least one previousoccasion.

Detentions were fairly evenly distributed throughout the week.About two-thirds of all detentions occurred in the eveningsor at night. The mean duration of detention under S136 was fourhours 30 minutes (range from less than 1 hour to over 15 hours).Of the detainees, 55% had presented with acts or threats ofdeliberate self-harm, 28% had presented with actual or threatenedviolence to others, while 16% were documented to have had evidenceof intoxication with drugs or alcohol at the time of arrest.

Broad clinical diagnoses were also recorded on the monitoringforms. Severe mental illnesses such as schizophrenia or bipolardisorder were diagnosed in 13%. More minor affective illnessesand anxiety disorders were diagnosed in 31%. Personality disorderwas present in 8% and substance misuse in 11%. Small numbershad learning disability (2%) and medical conditions (1%).

The outcome following assessment was: 61 detainees (33%) were admitted to a psychiatric hospital, 113 (61%) were not admitted and in 12 cases (6%) the outcome was not known. Of the 61 individuals who were admitted, just under half (46%) were detained and admitted under a further section of the MHA,1 the rest being admittedinformally without use of a Section.

Of the 113 individuals not admitted to hospital, no furtherimmediate assistance with mental health or social care needswas recorded for 65 (58%). The remaining 48 (42%) had assistancein a variety of ways: 22% were already known to community psychiatricservices and the relevant team was notified, 13% were referredto community psychiatric teams, 4% to specialist drug or alcoholservices and 9% to non-statutory agencies (including some drug/alcoholand counselling agencies). A further 13% were given assistancewith accommodation or travel.





Discussion

TOP

Abstract

Introduction

Method

Results

Discussion
ACKNOWLEDGEMENTS

REFERENCES

 

During the period of the study, the police cells were the onlydesignated POS in Gloucestershire. Police procedures for bookingin detainees taken to the cells are robust and we conclude,therefore, that the police data showing a mean of 192 subjectsdetained under S136 per year in the cells are likely to be accurate.Anecdotally, however, it was known to the authors that duringthe study period the police had, in a few cases, taken S136detainees to non-designated POSs including local psychiatrichospitals and hospital emergency departments. These detentions,which did not go to the cells, are unlikely to have been includedwithin the police data. However, the numbers were small andin our view they are unlikely to have affected the accuracyof the data in any significant way.

The same cannot be said for the mental health services data,which relies on clinicians and police officers filling out apaper form and sending it to a central collation point. Locallyit was already acknowledged, through discussions at inter-agencymonitoring group meetings on S136, that the paper form systemwas failing to capture all S136 activity. Our figures suggestthat, compared with the police data, this method only capturedabout 50% of the S136 detentions as the police data indicateda monthly average of 16 S136 detentions, while the other methodgave 8.5. Although the time periods for data collection usingthe two methods were different (2003–2006 and 2002–2004),they overlapped and we have no reason to think that rates ofS136 detention varied during this time sufficiently to explainthe wide discrepancy in detention rates shown by the two setsof data. We conclude, therefore, that the mental health servicesdata captured only part of the overall S136 activity, probablyabout 50%.

The demographic results and admission rates from the two datasets were similar. This supports the argument that the mentalhealth services data were representative of the overall S136activity. As such, we infer that the other findings from thatdata set are generalizable to the S136 population in Gloucestershire.

Compared with other published research on S136, recently reviewed,6 our study found lower admission rates (33–34% versus82–85%) and only minor over-representation of ethnic minorities.The reasons for these differences are unclear but may includeinaccuracies in data collection, geographical differences inclinical/police practice and different population groups.

The prevalence rates of the various categories of mental disorder also warrant some attention. As the categories were not defined, the ‘diagnosis’ was impressionistic and it is difficult, therefore, to draw firm conclusions. However, it is of interest that our finding of a low prevalence of serious mental illness (13%) and minor mental illness (31%) was associated with a lower admission rate than in other studies.6

Our study also showed a mixture of ‘risk’ behavioursassociated with detention. Acts or threats of self-harm werecommon (55%), but acts or threats of violence (28%) and evidenceof intoxication (16%) were only present in a minority. Thissuggests that those detained under S136 in Gloucestershire weremore likely to pose a risk to themselves than to others.

We also found that most S136 activity occurred in the eveningsand at night. This raises the question of whether, within workinghours, individuals in crisis are dealt with by other methods,with S136 acting as an important ‘safety net’ atother times.

Further research in this area would be useful. Very little isknown about what happens to those detained under S136 who arenot then admitted to hospital. Our study shows that 42.5% ofthose not admitted were offered further assistance, but whetherthey actually went on to receive that assistance is not known.Clinical experience suggests that they are characteristicallyindividuals who find it hard to access mainstream services.The finding that 9% of detainees had previously been detainedunder S136 was also of interest and raises the issue of whethermental health services and other agencies could do more to supportsuch individuals in the community, such that repeated detentionis not necessary.

Since this research was undertaken, a new ‘health-based’POS has been developed on the site of our local psychiatrichospital. We believe that this facility, which opened in early2009, will be of benefit to S136 detainees by providing an alternativeto the current exclusive use of the local police cells as aPOS. We would support the development of a national system formonitoring and recording use of Section 136 in all POSs.

 

 

 




ACKNOWLEDGEMENTS

TOP

Abstract

Introduction

Method

Results

Discussion

ACKNOWLEDGEMENTS
REFERENCES

 

We gratefully acknowledge the help and support in designingand conducting this research that we received from the followingindividuals: Sergeant Julie Gardener (Gloucestershire Constabulary),Julie Hapeshi and Chris Foy (Research Development and SupportUnit, Gloucestershire Hospitals NHS Trust), Dr Rhys Watkins(General Medical Practitioner and former Forensic Physician,Gloucestershire Constabulary), Dr Delia Parnham-Cope (Consultantin Emergency Medicine, Gloucestershire Hospitals NHS Trust).




REFERENCES

TOP

Abstract

Introduction

Method

Results

Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

  1. Mental Health Act. London: HMSO, 1983
  2. Dunn J, Fahy TA. Police admissions to a psychiatric hospital: demographic and clinical differences between ethnic groups. Br J Psychiatry 1990;156:373–8[Abstract/Free Full Text]
  3. Turner TH, Ness MN, Imison CT. Mentally disordered persons found in public places: diagnostic and social aspects of police referrals (Section 136). Psychol Med 1992;22:765–74[Medline]
  4. Spence SA, McPhillips MA. Personality disorder and police Section 136 in Westminster: a retrospective analysis of 65 assessments over six months. Med Sci Law 1995;35:48–52[Medline]
  5. Mokhtar AS, Hogbin P. Police may underuse Section 136. Med Sci Law 1993;33:188–96[Medline]
  6. Royal College of Psychiatrists. Standards on Use of Section 136 of the Mental Health Act 1983 (amended 2007). Draft Report. Report of a Multi-agency Group Organized by the Royal College of Psychiatrists, 2007
  7. Royal College of Psychiatrists. Standards on Use of Section 136 of the Mental Health Act 1983 (2007) (version for England). Royal College of Psychiatrists Council Report 149, 2008
  8. Docking M, Grace K, Bucke B. Police Custody as a ‘Place of Safety’: Examining the Use of Section 136 of the Mental Health Act. Independent Police Complaints Commission (IPCC) Research and Statistics Series: Paper 11, 2008
  9. Ogundipe L, Oyebode F, Knight A. Ambiguity in Section 136 of the Mental Health Act 1983: A survey of Section 12(2) approved doctors in the West Midlands. Psychiatr Bull 2001;25:388–90[Abstract/Free Full Text]
  10. Department of Health. Code of Practice. Mental Health Act 1983. London: The Stationery Office. 2008
  11. NACRO. Findings of the 2004 Survey of Court Diversion/Criminal Justice Mental Health Liaison Schemes for Mentally Disordered Offenders in England and Wales. NACRO, 2005
  12. Office for National Statistics. Census. http://www.ons.gov.uk/census/index.html, 2001

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