The Metropolitan Police Service (MPS) must improve its response to mental health to reduce the likelihood of deaths or serious injury occurring in the future, according to an independent report.
The Independent Commission on Mental Health and Policing reviewed 55 cases involving people with mental health issues over the past five years. Five cases were deaths in police custody, and 45 deaths were either prior to or following contact with the police. The other five cases resulted in serious injury.
In most cases the Commission concluded that failures in systems, mis-judgments or errors by individuals, resource limitations, poor co-ordination with other services or discriminatory attitudes towards people with mental illness led to these deaths.
Other key findings included:
• People with mental health issues complained they were treated like criminals by the police. They also felt individuals with mental health issues were handled with too much force, that the police should engage more with the families, and that police and NHS staff should have more mental health training
• Many families said they could not understand why there was not better liaison between agencies. Some professionals made similar points in evidence
• The Commission did have access to MPS files. However paper files and records were incomplete. This is unacceptable for a 21st Century, customer-focused police service
• Care pathways must be recognised and developed and there needs to be greater operational working together, such as inter-agency working within the NHS, clinical commissioning groups and local government
• The London Ambulance Service needs to respond to someone experiencing a clear mental health crisis as an emergency even if the police are present.
The report took evidence from an expert panel of commissioners; interviews and surveys with people who have mental health issues, the wider public and serving police officers; and through numerous meetings within the NHS and social services. It also includes the judgement of coroners, Independent Police Complaints Commission reports and the views of families.
Recommendations for change
The Commission has made 28 recommendations for change, falling under three areas for action: leadership, frontline and interagency working. They include:
• The mental health liaison officer role should be full-time and on a par with mental health trusts and supported by expert teams based on assessment of local needs
• The MPS should ensure that personal issues of mental health and wellbeing are incorporated into staff induction, and on-going mental health awareness training
• Mental health nurses with experience related to offenders must be available to all custody suites as required
• The police need to develop a safer model of restraint and the MPS has to work with Association of Chief Police Officers and the College of Policing on policy and training on restraint
• The MPS should establish joint protocols to identify a basis for effectively sharing information London-wide with partner agencies for adults at risk with mental health problems.
Lord Victor Adebowale, the author of the report, said: “I would like to offer my sincere thanks to the families of those who have died for their contribution to this report.
“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.
“The Commission has sought to provide actionable recommendations, so that there is a real opportunity for the MPS to change their approach significantly to those with mental health issues in their everyday policing.
“The report acknowledges that the MPS 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.
“I have been out on shifts with the police and the London Ambulance Service, so have seen at first hand that things can change and can change for the better.”