‘I’ve only got an AMHP warrant, a phone and some section papers’: day two on the AMHP frontline

9am

Team manager Robert Lewis has an email from the county’s Emergency Duty Team out-of-hours service.

Police custody staff are requesting AMHPs assess Katie* (not her real name), a woman who police officers found last night on a bridge threatening to kill herself after drinking a bottle of vodka.

Officers detained Katie under section 136 of the Mental Health Act. The police took her into custody as local NHS place of safety suites are not geared up to take people who are under the influence, Lewis explains (access to NHS place of safety is an issue in many parts of the country).

The next step is for an AMHP and a doctor to interview Katie. The aim is to see if she can be discharged or whether a full Mental Health Act assessment is required.

Under the Act, Katie can be held in custody for up to 72 hours. In practice, the AMHPs want to interview her as soon as possible. It has had to wait until this morning as Katie can’t be interviewed until she’s sober.

Mark Spraggs, the duty AMHP for Katie’s area, starts ringing doctors. The interview is pencilled in for 11am.

9.23am

The team’s referral board shows that the duty AMHPs covering Devon’s five rota areas currently have five assessments scheduled between them, fewer than at this point yesterday. I ask if this is a quiet morning?

Lewis laughs. “The Q word is banned in here. It always brings bad news,” he says. “We prefer peaceful.”

Sandy King, one of the team’s AMHPs, is up in North Devon carrying out an assessment. Another AMHP is starting slightly later than usual this morning after taking time back for a late finish earlier in the week. The team has a strict policy on AMHPs taking back extra hours worked. They don’t want staff burning out.

“It’s really hard to do some really complicated reports and pieces of work when the phone’s ringing so I understand why people work late to get that peace, just as long as they take their time back,” says Lewis.

9.54am

A referral comes in. A psychiatrist is requesting an assessment for a ward patient who is withdrawing from any support and refusing to eat or drink. The case is likely to require a discussion over whether the Mental Health Act or Mental Capacity Act is the most appropriate legislation to assess under.

It’s near to King’s other assessment in North Devon so she agrees to take it on.

“That’s basically Sandy filled up for the day. And it limits what else we can do now up in the north because we’re at capacity up there,” says Lewis.

10.15am

Spraggs has phoned five doctors. None are available to assess Katie.

“We’ve got an AMHP ready but no doctor so we can’t do the interview. Things can block the system that are out of our control,” says Lewis. “We shouldn’t, on a Friday morning, be struggling to get a doctor. It is something that’s being worked on to be fair – we’re talking to the Trust about it.”

11am

Spraggs has now tried 10 doctors without luck. The progress notes for the case are updated with each attempt he makes.

“We need the paper trail to show that we are trying our hardest to get this interview done. We really don’t want people sitting there for hours and hours,” explains Lewis.

One of the AMHPs who isn’t on duty today pops in to the office. She glances at the board. “Is it quieter today?,” she asks. “Sorry I meant peaceful…peaceful.”

“Well, at the moment there are no doctors available in Exeter, East or Mid Devon. If another assessment comes in we could be in trouble,” says Lewis.

11.30am

The curse of the Q word strikes. A social worker rings to request a Mental Health Act assessment for one of her clients.

It’s another case on Spraggs’ duty patch. If doctors had been available to do Katie’s interview this morning he could have started work on it straight away. Instead, he’s still trying to track down a doctor (he’s now tried 17 without success).

While Lewis phones Spraggs to tell him about the case, another two referrals come in.

“We’ve had three referrals in five minutes and we’re only just about dealing with what we’ve already got. This is starting to get a bit problematic,” says Lewis.

12.15pm

After trying 20 doctors, Spraggs has found one who can make Katie’s assessment. The only problem is he won’t be available until 2.30pm at the earliest.

Not wanting to leave Katie in custody for any longer than can be avoided, Spraggs tells Lewis he’s going to try a couple more doctors in an attempt to get the assessment done sooner. Ideally he wants to get a female doctor so there is a gender balance in the interview.

King phones from North Devon. She’s on her way to her second assessment.

“You’ve got the only doctor in North Devon right now so don’t let him go – tie him to you like you’re doing a three-legged race or something,” Lewis tells her.

12.30pm

The board is filling up with more referrals and tough judgement calls need to be made about which assessments to put first.

“These are all people in real distress but we have to take a step back and look at it dispassionately so that we can prioritise,” says Lewis.

“For example, one guy is in a nursing home so we know there are staff with him. He’s in a safer position, relatively, than someone else who is in the community.”

1pm

After 24 attempts, Spraggs has managed to get a female doctor for Katie’s interview at the custody suite (the most anyone on the team has seen without success is 27 attempts). The interview will happen at 1.30pm.

A different referral is causing some concern. A crisis team is requesting an urgent Mental Health Act assessment for Emma*, a woman who has made clear plans to end her life and has started taking a potentially-lethal staggered overdose of paracetamol (she is effectively poisoning herself gradually with steady doses of the drug over a long period).

Emma is refusing to answer the door or the phone to the crisis team or her doctors. Alexis Moran, one of the Central AMHP Team on duty, will take on the case.

1.20pm

Moran is facing a tough call on Emma’s assessment.  With Emma refusing to answer the door to any support teams, her doctor is convinced the only way AMHPs will get in to assess her is if they get a warrant giving police the power to force entry.

Moran is worried. Getting a warrant can take hours. You need to fill out the paperwork, get a court appointment, see the magistrates, phone the police and arrange their attendance for the assessment.

The team discuss the dilemma and make a call.

“We’re going to go out without a warrant. Otherwise by the time Alexis gets one, the woman could be dead,” says Lewis.

Ideally, Moran also wants to line-up a hospital bed in case Emma needs to be detained. The crisis team tells her there are none available in Devon at the moment but they will keep searching.

1.30pm

It’s time for Katie’s interview. Spraggs meets the doctor at the police custody suite.

The only room available for the interview to take place is tiny – barely big enough to squeeze in two chairs, a desk and a filing cabinet. Spraggs and the doctor decide the cramped conditions mean that doing the interview in Katie’s police cell is the “least worst” option.

Spraggs tells me later that he hates interviewing people in police cells and tries to avoid it wherever possible.

“Ideally we should be doing the interview at a hospital place of safety,” he says. “This morning, if I’d have had any idea it would’ve taken so long to get a doctor, I would’ve sorted that out. At the time Katie was asleep and I just wanted to get her interviewed as quickly as possible.”

2.50pm

Spraggs is back from interviewing Katie. She has been discharged from custody.

Spraggs now has to write-up his report. It is likely to take about an hour to complete all the necessary information, despite the interview being straightforward.

Lewis says that writing legally robust reports outlining the rationale and decision making for each assessment is one of the toughest parts of AMHP work.

“It can be so hard when you come back late at night, you’re absolutely knackered and you’ve then got to write-up a legally defensible report,” he says.

“Sometimes you’re just so tired it feels like everything that’s happened to you has just left your head.  It’s actually one of the most stressful, but important, parts of the job.”

3pm

King gets back from her two assessments in North Devon. “I’m shattered, there was so much traffic. I was stuck behind a queue of lorries,” she says. She now has to write-up reports from both assessments. Another few hours’ work at least.

3.40pm

Moran is standing outside Emma’s house. When she left the office half an hour ago, the crisis team phoned to tell her they’d found a bed. She has just been told the bed has fallen through. 

“That’s the kind of thing that can break you,” says Lewis. “When you’re out at someone’s house, sometimes late at night, and you find out the bed is no longer available.”

3.50pm

A tricky referral has come in. Doctors are requesting an urgent Mental Health Act assessment for a Devon patient who is placed out-of-area at an intensive care unit over 70 miles away.

Yet the team is at full stretch. All of the AMHPs are out on assessments or completing the reports they legally need to file.

The AMHP team in the local authority area the intensive care unit is in are unlikely to touch the case, says Lewis. They have their own referrals to handle, and a Devon patient is ultimately Devon’s responsibility.

In just over an hour, Devon’s Emergency Duty Team will come online to handle any out-of-hours work. However, it’s likely that they won’t cross the border to another county to take on the referral. If they did, it would take their emergency staff out of Devon for hours, Lewis explains.

“Why don’t you switch the phone off for a minute?” King tells Lewis. “This one’s going to need some thought.”

4.10pm

The team decides to log the fact that they can’t respond to the out-of-area assessment and submit it as a ‘risk incident’. Lewis’s incident report will now go to one of the NHS Trust’s senior managers who will decide what action needs to be taken on the referral.

Lewis has to assess the level of risk (1 – no risk to 7 – near miss) that the incident carries. He logs it as a 7, but admits it’s “really impossible for us to predict at this point”, particularly as the NHS system’s options don’t always cover the nature of the risk.

“People being placed out-of-area can be OK for planned assessments but for this kind of urgent response it can be a nightmare,” he says.

5pm

Lewis is writing up the daily email handover to the Emergency Duty Team.

Moran phones. Emma has been assessed and she has agreed to work with the crisis team. This is what being an AMHP entails – trying to secure the least restrictive way of dealing with crisis situations.

Lewis is shutting down his computer. I ask him how the last two days have compared to an average week for the team. He says they currently get three or four days a week like these. It used to be about one or two.

The resource pressures facing the various agencies involved in mental health are making it hard to manage expectations on the AMHP service, particularly as a lot of the services they require to support their role are out of their control.

“I always say to people that all I’ve got is an AMHP warrant card, a mobile phone and some blank section papers,” says Lewis.

“I have no control over beds, I have no control over doctors, I have no control over my colleagues in community teams or crisis teams or the police or ambulances. But I’ve got to use everything I can to help create an assessment in order to try to achieve an outcome that’s best for that individual. That’s the job.”

*Note: some names and details have been changed to protect anonymity.