Failings in police, social work and NHS joint working ‘contributed to’ mental health deaths

A series of systemic failings in the way police officers, social services and NHS staff work together have contributed to some deaths of people in acute mental distress, an independent commission has found.

A highly critical review of the Metropolitan police force’s response in 55 cases where people had died or suffered serious injury after contact with officers identified “significant problems” in joint working and warned that budget pressures on the NHS, social services and police forces had driven a culture of “buck passing” between agencies in some cases.

While examples of good practice were identified, the panel found it was “too common and too easy” for police officers, Approved Mental Health Professionals (AMHPs) and health staff to have “on-the-ground” disputes over their responsibilities, rather than focusing on the needs of people in mental distress.

“There are number of cases where the lack of communication between agencies or unnecessary gaps proved fatal,” the review found.

The sister of a man involved in a double homicide case reviewed by the panel told the commission: “The thing that was most upsetting was the breakdown, of a lack of liaison procedures between the police and [the mental health team] and AMHPs.”

The review, led by Turning Point chief executive Lord Victor Adebowale, was launched last year at the request of the Met after a series of deaths in custody involving people with mental health issues.

The panel made 28 recommendations for improving the way the police handle mental health cases.

A number of these referred solely to the Met – including the need to reflect the fact that mental health is “core business” for officers by introducing “mandatory” mental health training. But other recommendations apply to social services, including the need for the Met to agree joint protocols on AMHP responses and attain a formal mandate for a multi-agency mental health partnership board to drive improvements in joint working.

The majority of deaths reviewed by the panel involved suicide but five involved cases where people with mental health issues had died after being restrained by officers. It was “questionable” whether there was a need to use such force in any of the restraint cases reviewed, the panel found.

“The tactics and behaviour used to restrain people with mental health issues is the most disturbing of our findings and one over which the police have the power to take complete control to improve their practice,” the report said.
 
The review identified a series of failings in the emergency services response to mental health calls. The Met’s 999 call centres recorded “inadequate or inaccurate” information about mental health cases and failed to pass on critical information to frontline officers.

The report also found that the London Ambulance Service must respond to a clear mental health crisis as an emergency, even if the police are already present. The failure of ambulances to attend a number of mental health crisis situations had left police with “no option” but to transport people in mental distress in police vans, the panel said. 

“In a case from 2011 that is yet to come to inquest, a man suffering from an acute mental health episode was restrained and taken to hospital by police after an ambulance had been called but had not arrived. He died subsequently,” the report said.

“Poor coordination” between social services and police had led to confusion over ‘leadership and tactics’ when AMHPs and police officers undertook Mental Health Act duties together, the panel found. In cases where “police risk management supersedes AMHP risk management, the safety of a person may be compromised,” the report said.

AMHP availability out-of-hours and mental health bed shortages were also identified as contributing to delays in getting people the support they needed.

Despite being highly critical of the Met’s approach to handling mental health cases the panel also warned that the police “are having to mop up situations” that mental health and social services should be dealing with. Cuts to public spending meant “this was only likely to get worse,” the report said.

Speaking at the launch of the report, Lord Adebowale expressed his “sincere thanks” to the families of those who had died.
 
“Whilst a report like this cannot take away their suffering, I hope that those who receive this report, ensure that the recommendations are implemented in the name of the families as citizens who have lost loved ones in terrible circumstances. They deserve the reassurance that other families will not suffer the same loss,” he said.
 
“The report acknowledges that the Met cannot do all of this on its own. The inter-relationships between health and social care mean that many agencies must work together to provide a clear and effective system,” Adebowale added.

Ruth Allen, chair of The College of Social Work’s mental health faculty and a member of the commission, said health and social services bodies had a duty to act on the report as well as the Met.

“A key to that will be the mental health partnership board. The mental health trust executives in London need to own this, we need to make sure that social services leaders own this and look at addressing things like the issues around out-of-hours services, the protocols for work with AMHPs, and the response when people are in custody,” said Allen.

“Social care leaders also need to have that dialogue with local police to ensure that they are more involved in safeguarding too,” she added.