"34 year old female, under section, delusional, ready now"
It doesn't take long for mental health to rear its ugly head again. It didn't take long into the shift either too, 07:03 to be precise before we were off to a sectioning. In a change from the norm we were transporting from the A & E at one hospital to a specialist psychiatric hospital. There were no immediate safeguarding issues as she was in a place of safety so, in theory, it should be a simple load and go. Who am I kidding?! It's mental health! 'Simple' is never a word that is used around the transferring, admitting and sectioning of mental health patients. There is always far too much red tape, hoops to be jumped through, dragging of heels and differences of opinion, to make the simplest of things simple. Besides, where is the fun in having a fully accessed, ready to transport patient, complete with escort and a willing receiving unit?! Boring! We arrived at the hospital to a full welcoming party; lots of smiles, waves and enquiries after our health and wellbeing... OK, that's a lie; a miserable looking matron pointed at bed 1 and said 'she's in there'. That's more like it!
Our patient had been in hospital for 32 hours. There were points where she had been on the verge of discharge but due to relapses in her psychosis she had 'flipped' and become volatile and violent again. To calm her down they loaded her with diazepam in the hope she would be lucid for transport. It appeared to have worked! She was lying on the bed, asleep, husband by her side, and the AMHP who had been with her for 14 hours and on duty for 23! THIS was encouraging. We put the beds together to make the transition across an easy one. Her husband woke her, she looked at him, she looked at the nurse, she looked at us, she looked at the bed next to her, she looked at us again... then the shouting began. Not so lucid after all. After 20 minutes or so we had made no progress. No hospital staff had attempted to help us, the exhausted AMHP from the hospital we were taking her to was trying her best but failing. The patient's husband was shouting, the patient was shouting (in another language now) and then she got up and made a dash for the exit. We initially tried to stop her but the husband said she was going to the ambulance and the AMHP seemed keen to get her on board. We went with it and that is exactly what she did.
We now had a patient, under section, in the ambulance complete with belongings, notes and the husband. Where is the AMHP?! In her car. This concludes her involvement! It appeared we had the parcel, the music had most definitely stopped! NO NO NO NO NO NO NO! I went back into the hospital to remind them we were supposed to have an escort. I was told she wasn't their patient and there were no staff or security to send. Brilliant. I went back to the ambulance where our 'calm' patient was now trying to escape from the ambulance. She was not safe to transport in this way; we had no means to restrain her, nor the man power. We requested the police. This is the message we got back:
"Sorry, this is not in our remit; the hospital will need to provide an escort / security for the transfer"
I get it. Yes, that is what they are supposed to do but they haven't. This is not the hospital asking the police to be the escort, this is me, the ambulance, the police service's best mate if you will, asking for assistance. I went back into the hospital to say they had to provide security for us as it wasn't the police's remit. This was the response I got:
"We only have passive security here, if you need an escort the other hospital will have to provide it, not us"
I'd already been told by the AMHP before she foxtrot oscar'd that this was wrong and her hospital (15 miles away) had no one to send, nor was it in their remit. Back in the ambulance, my crew mate was assisting the husband to restrain the patient manually as she was lashing out, punching the windows and threatening suicide. This was starting to feel like a wholly inappropriate, possibly illegal situation. Do we actually have the power to restrain? I'm going with 'yes', as I was restraining her for my own safety, but it does beg another question: is the AMHP legally allowed to leave, abandoning a duty of care, especially to a vulnerable patient who's needs clearly reach beyond two girls in green?! Hmmmm! I made another request for police, as yet again they are the only people I can realistically turn to. This was the response I got:
"We will not be attending this CAD, it's a hospital issue"
Seriously, what are we supposed to do? The patient is now in our care, although the 'being in our care' was a contentious issue. The patient was under section and as such is in the care of the AMHP, but this care was apparently delegated to us (whether we wanted it or not) right before she scuttled off to her car. Unfortunately, had we not wanted to convey, her legal obligation to stay could not be argued with as she was now screeching away in first gear, grinning into the rear view mirror! Back to the matter in hand. The hospital wouldn't assist us, the police wouldn't assist us and our control had told us not to convey if we don't deem it safe. That is easy enough to say, but we can't walk away now; we can't leave her in the back of the ambulance, and letting her run off would make her a danger to herself and others. Why on earth were we in the back of an ambulance trying our best to calm down and restrain a patient in the first place?! This is not what we signed up to when we accepted the job! Remember me saying 'simple transfer'?! Why were the words 'violent' and 'aggressive' not mentioned when requesting an ambulance? Where was the risk assessment? Basically, there wasn't one, or if there was it was written on a tissue in the AMHPs pocket. I imagine it read something like this:
"Call ambulance, say hello, run away."
I'm hoping you now sense the sarcasm in the title! Sensing the delay and confusion over her 'imminent' transport she became violent; she scratched us, bit us and spat in our faces. The three of us, including her husband, were holding her, tears running down her husband's face. I requested police again, this time citing a crew emergency off the hospital premises. This was the response:
"Unit on way, ETA 2 minutes"
At last! Is that how it works?! We have to actually wait until we are bleeding for it to become a police issue? OK, I know that isn't the case but being stuck in a grey area, the police, hospital and ambulance all work within their own policy frameworks. Why, where mental health is concerned, is there not clear procedures in place for the transporting of mental health patients? In terms of restraint, who is best placed to do it? Us? The hospital? The police? I know there are vehement oppositions to restraint, and I only see it as a last resort, but in this case it was a necessity. Does a hospital A & E have the means to restrain for a journey to another hospital? Apparently not! Are the police the most appropriate body to restrain a patient during transport? Apparently not! That's the issue yet again, when it comes to mental health, no one really knows who is supposed to do what! By definition, mental health is a health issue; one that in my opinion should be treated and dealt with solely by the NHS. In reality, it is also a huge part of policing but surely an inter-hospital transfer is not part of policing? Maybe it is; maybe prevention of an assault is prevention of crime! I know for a fact the police will say that the mental health teams are more than equipped to deal with it, and theoretically they are (see this post by Mental Health Cop explaining his stance on what the police should be doing). The problem is they don't play ball, and when they don't play ball, something has to give. Personally, if an ambulance crew requests police to their location then that is what they should get! Thoughts?
I'd love comments / thoughts from police, ambulance staff, hospital staff, AMHPs and anyone who has an opinion on these issues! Get talking!!