Kingsley Burrell

ASSOCIATION OF

AMBULANCE
CHIEF EXECUTIVES

NHS)

Association of Ambulance Chief Executives

3 floor

13 July 2015 32 Southwark Bridge Road

. London
Mrs Louise Hunt SE1 9EU
Senior Coroner
Birmingham and Solihull Districts me
50 Newton Street
Birmingham
B4 6NE

Dear Mrs Hunt
KINGSLEY BURRELL (DECEASED)

Thank you for your Regulation 28 Report to prevent future deaths, dated 20 May 2015, bringing to
my attention the Coroners concerns arising from the inquest into the death of Kingsley Burrell.

The Association of Ambulance Chief Executives (AACE) provides ambulance services with a
central organisation that supports, coordinates and implements nationally agreed policy. It also
provides the general public and other stakeholders with a central resource of information about
NHS ambulance services. The primary focus of the AACE is the ongoing development of the
English ambulance services and the improvement of patient care.

We have given careful consideration to your concerns and have consulted with the mental health
leads and senior clinicians in the NHS ambulance trusts.

Taking the concerns in turn, | set out the actions we have taken and response:

1. Medical evidence at the inquest confirmed that Mr Burrell was suffering from acute
behavioural disturbance. As a result he continued to struggle against restraint.
Patients with this condition are at risk of death through prolonged restraint and
{ struggle against restraint. Most training in relation to restraint deaths focuses on
: positional asphyxia. Position in this case was not a major consideration. It was clear
from the inquest that there was a lack of understanding of how to treat someone with
an acute behavioural disturbance. Minimising the period of restraint is key. West
Midlands police have undertaken considerable work and training of staff concerning
this condition. My concern is that this has not been rolled out nationally and therefore
many other forces will not understand the implications of this condition and how best
to treat it. | suggest contact is made with Chief Inspector HM at WMP for full
information on the changes made in the West Midlands area.

We sent a survey to the mental health leads of NHS ambulance trusts asking if they had a restraint
policy and what training and education is currently provided to front line staff around acute
behavioural disturbance.

We established that ambulance trusts currently do not have specific policies regarding restraint.
Some trusts are currently developing a restraint policy or have wording around restraint in other
trust policies such as capacity and consent to treatment. We also established that not all trusts
comprehensively incorporate education to their staff around ABD.

The National Ambulance Mental Health Leads group that reports to the National Ambulance
Service Medical Director group (NASMeD) have been asked to develop the principles and

Chairman: Dr Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc FAS!
Managing Director: Martin Flaherty OBE

recommend what should be part of policies around conveyance of mental health patients,
highlighting the principles of restraint and awareness of acute behavioural disturbance. This will
include an awareness of the impact that prolonged restraint can have on an individual and the
importance of performing physica! observations during and after physical intervention/restraining.
Also the importance of documenting that any physical intervention has been used on a person.
This group will then share these principles with ambulance trusts for them to consider
implementation. This action will be completed by November 2015.

We have made a recommendation to the National Education Network for Ambulance Services
leads (NENAS) that each trust considers including, if not completed already, the education of front
line staff and control room staff in acute behavioural disturbance to raise awareness of the
condition and how it can present in a patient.

We have approached the leads of the two systems used in ambulance control rooms that triage
999 calls and asked them to review their triage pathways to ensure that ABD is included or referred
to in the questions that are asked (AMPDS and NHS pathways).

An ambulance guideline development group is currently working on revising the UK ambulance
services clinical practice guidance around the management of mental health patients. This will
include aspects of restraint and include recognition and management of patients with ABD. This
work will be completed in 2016 and will be incorporated into the guidance used to inform the
Clinical practice of ambulance clinicians across the UK.

Ambulance clinicians are legally authorised and obliged under the Mental Capacity Act to act in the
best interests of, and provide treatment for, patients who lack capacity, even where the patient
refuses treatment or are abusive, threatening or violent.

The Mental Capacity Act also supports the use of reasonable force to ensure that patients lacking
capacity receive care that is in their best interests or are protected from further harm. However
ambulance clinicians are neither trained nor expected to restrain patients who are acting in a
threatening or violent manner. Ambulance staff are trained to provide minimal restraint and use soft
control technique/physical intervention in cases where patients lack capacity and there is no
perceived risk of harm to them or the patient. In the event of restraint being required for a violent
patient ambulance staff will continue to rely on the Police to provide that restraint as their officers
have been specifically trained to do so. In these instances ambulance staff are required to monitor
the patient to ensure their continued safety.

2. The West Midlands area now have a crisis team that works with people who are in a
mental health crisis. This involves a mental health worker and ambulance crew
working together with the police to try to help patients with acute mental_health
disorders. My concern is that this is not a national system. Chief Inspector a:
West Midlands Police can provide full details of the scheme.

3. This case has resulted in a multi-agency review of how patients are managed
between the services when crisis occurs. A new conveying of patients policy has
been devised. Critically police now only attend a mental health ward if there was a
patient who is threatening staff or if there is disorder on the ward. My concern is that
this is not reflected nationally. Chief Inspector JJ at West Midlands police can
provide full details of the policy.

In the survey we sent to trusts, we asked what schemes were in existence around multi
agency working. We found that there were a variety of schemes, some in pilot stage and still
being reviewed in terms of effectiveness and efficiency, others in planning. Some of them
had paramedics working as part of a joint team, others had pathways where paramedics
could refer to mental health teams.

Chairman: Dr Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc FASi
Managing Director: Martin Flaherty OBE

Due to a now recognised national shortage of paramedics, being able to provide a paramedic to
specifically work as part of a team to respond to patients with acute mental health disorders will be
difficult for some trusts, and will depend on local commissioning arrangements. We recognise that
these schemes are likely to continue to develop.

Ambulance trusts do work closely with their local Police Forces, and we found that most trusts
have at least three police forces within their region. Therefore it is important to ensure that
collaborative arrangements are in place to jointly manage a range of incidents including the multi-
agency response to patients experiencing mental health crisis.

At a national level the AACE and the National Police Chiefs Council (NPCC) have been working
closely together to improve arrangements for inter-agency working and the demand that
ambulance trusts and police forces generate for one another; the aim being to improve the
response to the public whilst also operating together as efficiently as possible. Particular efforts
have been expended in relation to offering better care to patients experiencing mental health crisis
and the Crisis Care Concordat, supported by local declarations, have given added impetus to this
work,

AS a consequence ambulance trusts in England introduced new protocols in April 2014 designed to
improve the speed of response to patients detained under Section 136 of the Mental Health Act in
order to offer a clinical assessment more quickly and to arrange subsequent conveyance to a place
of safety more efficiently. Data for 2014/15 indicates that there have been encouraging
improvements with 74% of incidents where the police requested an ambulance receiving a
response within 30 minutes. AACE continue to work with the NPCC, Home Office and the
Department of Health to drive further improvements in both the speed of ambulance response and
the proportion of patients conveyed by ambulance rather than police vehicles. In the respect of the
latter recent Home Office data indicates that for Section 1386 where patients were conveyed by the
Police 43% of cases were due to risk or behavioural issues and in 32% of cases no ambulance had
been requested by the police. AACE continue to work with the NPCC to ensure that an ambulance
is always requested and that police conveyance is reduced to as low a rate as possible.

The College of Policing, Health and Ambulance Service representatives are currently working
together to devise a national protocol for the management of ABD in the pre-hospital setting. This
is a complex piece of work but the impetus certainly exists to ensure a suitable outcome is reached
that will be both manageable and of course beneficial to the patients concerned.

| hope that you will agree that we have dealt comprehensively with the concerns that you have
raised. We will continue to ensure co-ordination between ambulance trusts who have shown
themselves to be absolutely committed to learning from this tragic event and do everything within
our power to prevent it happening again in the future.

Yours sincerely

QD. C.marsh.

Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc FASI

Chief Executive, West Midlands Ambulance Service NHS Foundation Trust
Chief Executive, East of England Ambulance Service NHS Trust
Chairman, Association of Ambulance Chief Executives

Chairman: Dr Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc FASI
Managing Director: Martin Flaherty OBE

doh Rt Hon Alistair Burt MP

Minister of State for Community and Social Care

Department
of Health
Richmond House
79 Whitehalf
London
SWIA 2NS

POC3000948033

Mrs L. Hunt Pe
Senior Coroner

50 Newton Street

Birmingham

Evans 20 JUL 2015

Deve Mrs unk ,

Thank you for your letter of 20 May 2015 following the inquest into the death of
Kingsley Burrell in March 2011. I was very sorry to hear of Mr Burrell’s death and
wish to extend my sincere condolences to his family.

You note that Mr Burrell was restrained for a total of two and a half hours during a
period of detention under the Mental Health Act. The inquest jury found that this
was an unreasonable period of restraint which, together with the covering applied to
his head, the delay in instigating resuscitation and neglect, contributed to his death.

You raise a number of concerns, some of which are for our response:

e Mr Burrell struggled against his restraint as a result of suffering an acute
behaviour disturbance. The West Midlands area now has a crisis team that
work with people in mental health crisis — this involves mental health
workers and ambulance crew working together with Police to help
patients with acute mental health disorders. You are concerned this is not
a national system.

e This case has resulted in a local multi agency review of how mental
health crisis patients are managed between services and a new policy for
conveying patients has been devised. This means that police only attend a
mental health ward if patient is threatening staff or disorder on the ward.
You are concerned that this policy is not reflected nationally.

On restraint, both statutory and non-statutory guidance exists. The Mental Health
Act 1983 Code of Practice (the Code) was revised in 2015 and provides statutory
guidance on the appropriate use of restrictive practices that protect the dignity and
safety of patients. The Code is clear that any restraint should be the least restrictive,

proportionate to the risk of harm to the person and others, and used for the least
amount of time appropriate to manage the risk. The Code states that there should be
local policies in place between NHS bodies and the police which should have a clear
protocol about the circumstances when, very exceptionally, police may be asked to
use physical restraint in a health-based place of safety.

The Department of Health has also published guidance on the reduction of restrictive
practices which sets out the appropriate use of restraint. The Department’s Positive
and Proactive Care: reducing the need for restrictive interventions (2014) guidance
echoes the requirements of the Code and sets out guidance in more detail around the
use of restraint.

During restraint, people must not have their mouths and/or noses covered. The use of
mechanical restraint must be exceptional, as a response to extreme violent
behaviour, to ensure the safety of the person and professionals.

The guidance also states that, when confronted with acute behavioural disturbance,
the choice of restrictive intervention must always represent the least restrictive
option to meet the immediate need. It should always be informed by any particular
risks associated with the individual’s general health and an appraisal of the
immediate environment. Factors which suggest a person is at increased risk of
physical and/ or emotional trauma must be taken into account when applying
restrictive interventions.

Both the Code and the guidance make clear that all types of restraint should be used
for the least amount of time needed to manage risks to the individual and others.
Department officials continue to work with the police, the Royal Colleges of Nurses
and Psychiatrists, and Mental Health Trusts to develop further guidance and training
to support local protocols, so that all partners are clear about what should happen in
these circumstances.

The Department published “Positive and Safe” in April 2014. This is a two-year
programme which aims to end unnecessary use of restrictive interventions across all
health and adult social care. The programme incorporates two key pieces of
guidance — the Positive and Proactive Care guide mentioned above and A Positive

and Proactive Workforce.

Whilst we aim to reduce restrictive practices, there will always be circumstances in
which it is necessary to use restraint. When restraint is used on patients who are
suffering a period of conflict or disturbed behaviour, their physical responses to
stress and anxiety may be heightened and a worsening of pre-existing medical
conditions can occur. It is therefore vital to observe the patient to monitor for
deterioration in health,

ae

Department
of Health

NHS England has responsibility for patient safety and is aware of the importance of
performing physical observations during and after physical intervention or restraint.
Discussions are currently focusing on the risks posed to patients in mental health
care where continued physical observations are not undertaken during and following
a period of restraint.

NHS England shared the details of Kingsley Burrell’s death with the Expert Safety
Group for Mental Health (a group with representation from the health and voluntary
sector) on 29th June 2015. They discussed the wider issues this case highlights for
all care settings across the NHS.

The Expert Group has helped support the development of a “Mental Health Patient
Safety Thermometer”. This measures the prevalence of specific types of harm for
every patient including use of restraint. This helps local teams to develop and
implement improvements to restraint practice. Teams using the survey tool can
access data from other teams to provide a wider picture of the prevalence of restraint
across NHS organisations.

The National Reporting and Learning System ( NRLS) is a comprehensive database
of patient safety information. From April 2015 it became a requirement to report all
incidents where harm has been caused by restraint as separate patient safety
incidents. In this way, important patient safety issues can be identified and tackled
at the root cause.

You highlight the need for cross-agency working to safely manage people being
moved between services when a mental health crisis occurs and when police attend a
health setting. The Code states local policies should be in place between providers,
the police and other agencies with protocols covering all aspects of the use of section
135 and 136 powers. Sections 135 and 136 give the police powers to temporarily
move people, who appear to be suffering from a mental disorder, and who need
urgent care, to a ‘place of safety’ so that a mental health assessment can be carried
out and appropriate arrangements made for care. Local policies should include
arrangements for police attend a health-based setting and transporting people
between places of safety.

The Department published the Crisis Care Concordat in 2014 to ensure that anyone
experiencing a mental health crisis receives the right support in the right place. The
Concordat is a cross-sector agreement which ensures that local areas provide the

appropriate response to people in mental health crisis. Every local area in England
now has a local mental health crisis plan in place to ensure this happens.

The Department has also funded a number of street triage pilot schemes where
mental health professionals provide on the spot advice to police when dealing with
people with possible mental health problems. These pilots are currently being
evaluated so that this approach can be rolled out more widely.

The Association of Ambulance Chief Executives (AACE) is developing principles
and policies for the conveyance of mental health patients and restraint which will
cover the importance of physical observations during and after physical intervention.

AACE recommends that awareness of acute behavioural disturbance is raised with
front line and control room staff at all ambulance trusts. AACE reports that there are
a number of schemes for multi-agency working at ambulance trusts. AACE has
worked nationally with the National Police Chiefs Council (NPCC) to improve inter-
agency working and the efficiency of responses to the public, particularly to those
patients experiencing mental health crisis.

AACE will be responding separately to your concerns and will no doubt provide you
with further detail about their work.

I hope that you find this reply helpful and I am grateful to you for bringing the
circumstances of Mr Burrell’s death to my attention.

Yours Sincaraby
£A9-
(rat ae

ALISTAIR BURT

ihedetheta TOTAL POLICING

Territorial Policing

Commander Christine Jones QPM
Commander
Territorial Policing

New Scotland Yard
Room 1034

10 Broadway
London

SW1H OBG

Mrs Louise Hunt

Senior Coroner

Birmingham and Solihull Districts
50 Newton Street

Birmingham

B4 6NE

Monday 20th July 2015
Dear Mrs Hunt
Re: Kingsley BURELL (deceased)

Thank you for your letter dated 20 May 2015, and my apologies for the delay in responding to your
Regulation 28 Report to Prevent Future Deaths.

My role is that of the lead for policing and mental health for all forces across England and Wales,
consequent of my appointment to lead this work on behalf of the National Police Chief's Council
(formerly the Association of Chief Police Officers, or ACPO). This is in addition to my roles and
responsibilities as a Commander in the Metropolitan Police, where | also have the Force lead for
policing and mental health and for Domestic Abuse.

| have read and absorbed the details of this very sad case and am grateful for the opportunity to
respond in my capacity as national lead for policing and mental health to the three points you make as
Matters of Concern on page 2.

Point 1

Medical evidence at the inquest confirmed that Mr Burrell was suffering from acute behavioral
disturbance. As a result he continued to struggle against restraint. Patients with this condition are
at risk of death through prolonged restraint and struggle against restraint. Most training in relation
to restraint deaths focuses on positional asphyxia. Position in this case was not a major
consideration. It was clear from the inquest that there was alack of understanding of how to treat
someone with an acute behavioural disturbance. Minimizing the period of key restraint is key. West
Midlands Police have undertaken considerable work and training of staff concerning this condition.

My concern is that this has not been rolled out nationally and therefore many other forces will not
understand the implication of this condition and how best to treat it. | suggest contact is made with

Chief Inspector | og WMP for full information on the changes made in the West Midlands
Area.

Whilst it is helpful that West Midlands have cited their activity in respect of positional asphyxia and
other risk factors associated with restraint, it is not accurate to suggest that the force has implemented
safe practice independent of all forces nationally. Indeed, Acute Behavioural Disorder (ABD) and
Excited Delirium were specifically highlighted in a 2010 Guidance Document issued by the former
National Policing Improvement Agency (now renamed The College of Policing). The NPIA then ran a
series of national events throughout 2010/2011 where every single force in the country was briefed
and provided with training materials to address this specific set of risks.

In 2013 the national poling lead for Officer Safety Training requested the College of Policing to review
national compliance in ABD training. Although the findings were varied, overall compliance was to
standard in relation to the prominence these risks were given within training packages. Uniformity in
terminology and the ability quickly to embed learning outcomes are issues the College continue to
progress.

In this tragic case, police officers were called in to a mental health environment to effect restraint upon
a patient. Aside from the moral and ethical issues pertaining to police officers entering into a care
environment to effect this type of force, | am examining the whole issue of the role of police in these
types of circumstances and indeed whether this is simply an issue of a lack of capability, capacity and
training for health practitioners rather than that it is and should be presumed a police matter. | hope
you will be reassured to know that to this end | have been working with the College of Policing and
have instigated an expert reference group, chaired by Lord Alex Carlile, to ascertain not only the legal
platform upon which activities should sit, but further who should effect them and what is defined as
safe practice across all public service disciplines. This work will also inform evidence based advice on
types of restraint, who should direct and own them, and how and by whom clinical health is actively
monitored and prioritised. | should be delighted to share this with you as work progresses.

It is my view, and that of policing nationally, that there is NO safe period for restraint, and our officers
are taught accordingly that restraint of any type is a risk which must be mitigated through close
supervision of the individual under restraint, including vital sign observation, positional relief and an
understanding of the impact upon breathing ability when handcuffs are used in certain positions.
When mental ill health is apparent in restraint cases, all officers are instructed to treat this as a clinical
emergency and to immediately call for emergency ambulance support. The ability, however, of local
ambulance services to meet demand is another issue, and actual provision varies significantly.

Point 2

The West Midlands area now have a crisis team that works with people who are in a mental health
crisis. This involves a mental health worker and ambulance crew working together with the Police
to try to help patients with acute mental health disorders. My concern is that this is not a national
system. Chief Inspector iat West Midlands Police can provide full details of the scheme.

The activity referred to above is known nationally as ‘Street Triage’, which at this stage does not
conform to a prescribed template and therefore the nomenclature does not necessarily describe the
local arrangements in place. Broadly, it is often joint service patrols between police and mental health
professionals and is intended to address crisis or pre crisis cases which would otherwise result in the
exercise of restrictive powers under the Mental Health Act 1983 (usually Section 135 or 136). There

is much work yet to be done to ascertain the value and capability of street triage services where they
exist, and there is much evidence thus far that they are by no means sustainable in their myriad of
current forms. Indeed, perhaps their very presence describes the paucity of capability in accessing
appropriate mental health service without the involvement of police. Their formation, however, is a
direct result of the work | conducted with Geraldine Strathdee of NHS England when we first explored
the pertinence of patient history as a component part in decision making when considering the
exercise of powers under the Mental Health Act. This came as a precursor to the Crisis Care
Concordat.

All areas of the country are now committed to the Crisis Care Concordat, the formation of which | was
heavily involved in, and progress against local action plans is perhaps the best indicator of progress in
providing accessible, 24/7 crisis and pre crisis care.

It is of note, however, that in the case of Mr BURRELL ‘street Triage’ services would absolutely not
have been deployed as he was already within the confines of a Mental Health environment.

Point 3

This case has resulted in a multi-agency review of how patients are managed between the services
when crisis occurs. A new conveying of patients policy has been devised. Critically police now only
attend a mental health ward if there was a patient who is threatening staff or there is disorder on
the ward. My concern that this is not reflected nationally. Chief Inspector f | at West Midlands
Police can provide full details of the policy.

Chief Inspector Russell has cited my own national instruction to Chief Officers in respect of the
monitoring and reviewing of all service requests to mental health environments, and for escalation and
supervisory involvement on every occasion where police are requested to, or effect, restraint in a
health environment whatever the circumstances.

This is to assist my work with the expert reference group and to ensure a clear picture of demand and
need is presented. The multi agency membership includes NHS England, the Royal College of
Psychiatrists, the Royal College of Nursing, NHS Protect, the Department of Health, the Home Office,
the Care Quality Commission, the IPCC, NICE, the College of Policing and others, and will report
initial findings regarding the role of police in mental health settings by the end of this calendar year.

| do hope that the above answers your concerns, but please do come back to me if there is anything
further with which | can assist, of if you require clarity in respect of the commentary | have provided.

Yours sincerely

Commander, Metropolitan Police Service
National Police Chiefs Council Mental Health and Policing Business Lead