‘Snow brings an extra complexity to social work assessments with the homeless’

It’s a freezing Friday night. I am on approved mental health professional (AMHP) duty in inner London. Head down, hands thrust into pockets, I trudge through the back streets from the team’s base to the police station.

The practicalities of today’s assessment are on my mind. A man was arrested last night. The custody sergeant described him as “clearly unwell” and felt the station “isn’t the right place for him”. 

The cell CCTV shows some bizarre behaviour

I found the man’s name on the database but, beyond registration as a temporary patient at a GP practice for homeless people, there are no real details.

He has apparently been “uncooperative and hostile” with the police and the forensic medical examiner. The cell CCTV shows him exhibiting some bizarre behaviour.

I’ve already taken some decisions, in part influenced by the weather, and have arranged two psychiatrists to meet me at the police station for a full Mental Health Act assessment.

In other circumstances I may have tried to see the man first. But today, with the risk of London grinding to a halt due to the snow and the credibility of the sergeant’s concerns in my mind, I’ve jumped forward a stage.

There are questions on my mind. What if he doesn’t need an admission? What if the police drop the charges? Where will he stay tonight?

Coping in the snow

I think back to the street homeless man I’d seen two days earlier. No snow then, but still freezing cold. He hadn’t responded to me or anyone else, including the police and outreach workers who offered him shelter.

Concerned that he was at imminent risk and might lack capacity I had called an ambulance. Before it arrived he finally got up, neatly rolled up his sleeping bags and, still without saying a word, left. 

Myself and the police officers present concluded that there weren’t grounds to use the emergency powers available. So the man made his way and there was nothing to do but alert other agencies and for me to come back another day.

Now I’m thinking, was that the right decision? How would he be coping with this snow?

The schools are off

I think back to this morning before work. My son was arguing the case against going to school given the forecast, yet refusing to wear a sensible number of layers of clothing.

Later my mobile goes. Two unread messages. One from each of my children’s schools. Both are closing early due to the weather.

I ring home. All is in hand, but what will my eventual journey back be like? I make a work call, giving a ‘heads up’ to an outreach team to check shelter options in case the man in the police station needs to use them later.

The assessment

Back at the police station I’m soon joined by my medical colleagues for the assessment. We speak with the custody staff, review the CCTV footage, and interview the man in his cell.

We all agree that he does appear to be mentally unwell. He has disclosed some drug use before his arrest but it is has now been too long for his current presentation to be due to acute intoxication.

He doesn’t appear able to cooperate with a less restrictive plan and he meets the criteria to be admitted for assessment under section 2 of the Mental Health Act 1983. 

He was too guarded to give us much information but he did mention “his” hostel in another part of the country. There’s no mobile coverage in the police station and there’s no computer in the medical room, so I self-consciously stand behind the custody desk and borrow a police computer to “Google” the hostel.

Ten minutes later I’ve established that not only does the man have an address, he also remains open to mental health services in that area and has an established diagnosis. The two doctors sign their forms and leave. I know I won’t be going anywhere for a while yet.

Contravening normal protocol

I don’t leave for another five hours, and even by then not everything is resolved. In contravention of the normal protocol that once you start an assessment you stay with it, I have handed over to a colleague from the emergency duty team who has kindly taken on board my concerns about my journey home.

The delay has in part been caused by my own insistence that the combination of this man’s mental state, and the road conditions outside, have made it inappropriate to convey him many tens of miles back to his home city.

I insist that a bed needs to be found locally but am told that there are no suitable NHS beds available, and authorisation for a private bed needs all sorts of extra sign-offs and debate.

Reflection

A week has passed. I did get home that night and the man from the police station is back in his home city under the care of the team that knows him. My son never did get a full day off school but appears a little more willing to dress for the weather.

The street homeless man who I’d seen earlier in the week is still sleeping outside and I’m still not convinced what the right course of action should be.

This week I’m delivering training to other AMHPs on homelessness and the use of the Mental Health Act. It is an area where I have particular experience.

I also know that in this role there are so many legal, ethical and practical challenges to consider and balance that it would be foolish not to want to hear others’ views about the decisions they would make and how they would reach them. 

Sometimes it is clear what the right decision should be. If the weather is mild and you are considering the use of the Mental Health Act for someone who is street homeless you are more likely to want to gather more information and continue an assessment over time, than detain someone.

But when there is still snow on the ground, things are sometimes not so clear.

Barney Wells is a social worker and AMHP in central London and a spokesperson for The College of Social Work.