An independent review commissioned by Staffordshire’s Police and Crime Commissioner Matthew Ellis into why a seriously ill man spent 64 hours in police custody has highlighted disjointed services and a lack of accountability and responsibility.
The Ethics, Transparency and Audit Panel (ETAP) examined the case which saw the man, who was in mental health crisis, kept in custody despite not committing a crime because a suitable NHS services weren’t available.
The Commissioner previously made public the shocking three-day timeline of last March’s incident, which highlighted a series of phone calls, texts and conversations with mental health professionals that failed to help find a suitable place of safety for the 48-year-old man, who absconded from a mental health unit in London and ended up in Stoke-on-Trent.
The county-wide ETAP was established by the PCC in 2013 under his ‘New Dawn of Transparency’ agenda. It is made up of members of the public who have become expert citizens and has received national recognition for its scrutiny of the police use of Taser, stop and search and crime recording in Staffordshire.
ETAP’s 31-page review included the following findings:
- There were two missed opportunities for police to detain the man earlier
- It was not clear which clinician had overall responsibility for the man’s medical treatment while in custody
- A lack of staff at the man’s ‘home’ hospital in London meant information about him was not quickly available. The hospital was unable to provide a bed
- The NHS Mental Health Team contacted 11 different places to try and find a suitable Psychiatric Intensive Care Unit (PICU) bed
- A PICU bed was eventually found in Manchester but withdrawn
- A PICU bed was then offered in Bradford. Suitable patient transport was delayed for several hours. The bed was withdrawn while the man was in transit, forcing a return to Stoke-on-Trent
- A whole police custody wing had to be cordoned off because of the man’s condition
- At least 22 police officers were involved in the incident over the long weekend
- Despite the best efforts of police, the man’s condition deteriorated while in custody
- At one point, the man was kept in a vehicle for over two hours in the car park outside police custody facilities due to the deadlock before he was finally taken to Harplands Hospital in Stoke-on-Trent.
Mr Ellis said the report comes at a time when progress has been made across agencies in Staffordshire and Stoke-on-Trent to make sure people in mental health crisis get the right support. This has seen NHS and police staff work closely together and led to the number of people detained in police custody under the Mental Health Act fall by 80 per cent. Funding has been secured for an expansion of Harplands Hospital in 2017 which will include PICU beds.
The Commissioner said: “Senior NHS Trust managers across the country failed to get a grip of the seriousness of this situation meaning an individual in distress was left in a criminal justice environment for so long. It also meant that police officers were left to deal with mental health complexities on a scale which was way outside their expertise.
“This isn’t about criticising front end mental health professionals, this is about a failure of senior NHS managers to be accountable.
“The ETAP report reinforces a lack of join up and responsibility across services, in particular NHS Mental Health Trusts across the country.
“The last two years in Staffordshire have seen an 80% reduction in the number of people suffering mental ill health being put in cells but this sad incident reinforces the importance of senior people being accountable in providing decent services in difficult situations.
“There are senior managers across NHS Trusts countrywide who must take some responsibility for this situation where a man was incarcerated for 64 hours despite not committing a crime and two dozen police officers were tested to their absolute limit.”
Assistant Chief Constable Bernie O’Reilly, from Staffordshire Police, said: “I welcome the review and learning that has come from it. Our custody facilities are rarely the right place for prolonged periods for people with mental health issues. Our officers do their best in difficult circumstances – but are reliant on qualified experts to provide appropriate alternative accommodation that better suits the needs of people in distress.”
