HSJ’s fortnightly briefing covering safety, quality, performance and finances in the mental health sector.

The new emergency mental health targets will bring greater attention to a long-standing problem.

But there are also less visible poor practices that will not easily be fixed by a mandate.

Self-harm is one of the most common reasons why someone with a mental health need ends up in accident and emergency, voluntarily or otherwise.

But too often in conversations with patients, the word “punitive” comes up about the treatment they receive.

Two female patients that I spoke to – whose stories you can read below – said they were searched, restrained by security guards, had their belongings taken away, left to wait for hours without explanation or communication, and denied their liberty without any clear explanation.

One of the women described a practice which should have long been abandoned, where a liaison psychiatry team would not see a patient until they are “medically cleared”.

While addressing the deep-rooted cultural attitudes towards those who self-harm will require whole-scale societal change, there seem to be policies in use across some NHS services which encourage a punitive approach, when what these patients need is help.

Mind the gap

There appears to be a gap in the legalities around depriving a patient of their liberty within A&E, when they are not subject to the Mental Health or Mental Capacity Act, and have not been brought in by police under section 136.

The “common law” rules are also ill-defined and inconsistent.

So, are there frequent instances in which patients are illegally detained in A&E? This is unclear and in the absence of a law degree I will not attempt to debate the legalities.

However, regardless of where you stand on the legal uncertainties, there are some very clear improvements that can be made in the approach towards self-harm within A&E, which will come from training and better communication with patients.

Alex Thomson, consultant liaison psychiatrist at Northwick Park Hospital, describes a better approach: “Respect, trust, understanding and timely assistance from liaison psychiatry are crucial to help people get better. If people are stopped from leaving, the reasons and legal basis should be clearly explained, and they should be attended to by a nurse or health care assistant.”

“It’s distressing and frightening when you’re having your clothes cut off you”

Clare, who attended A&E at a London trust last year, told HSJ: “What I experienced there was similar to what I have experienced in a number of London departments. Immediately on them realising my attendance was related to self-harm, I was assigned security guards and their job was to stand next to me and prevent me from leaving.

“It’s usually either one or two people, almost always men, which is distressing and frightening when you’re having your clothes cut off you. It wasn’t something I consented to.

“The department also assigned secure registered mental health nurses, but these acted as security guards too. I wasn’t given their name and they didn’t interact with me except to grab me when I tried to leave, pin me down and shout at me.

“Unfortunately, that time I was in hospital the consultant who was treating me didn’t behave well. He demonstrated stigma and a poor attitude to self-harm. I was to strip off my clothing and have a cold shower whilst being watched by nurses. He didn’t speak to me but shouted at me.

“It was frightening and traumatic. I wanted to leave. So, I started asking ‘please let me go’. I must have said it 100 times. When I tried to leave, I was physically stopped and pinned down by the male ‘secure RMN’ and other male staff. I was shouted at, had my bag confiscated and my possessions were also searched, just because it was self-harm, not because I posed a risk to anybody. I was told to ‘stop playing games or you’ll be sectioned’.

“I was prevented from leaving for five hours. I have had experiences before in excess of that, sometimes up to two, three, or four days. On this occasion I was forced to have treatment and investigations that I didn’t consent to. I was forced to have arterial blood gas testing and other invasive tests; I wasn’t offered any pain relief. That has happened to me a lot with self-harm…

“Initially they said I couldn’t leave, but after five hours when a medical doctor from elsewhere in the hospital spoke to me, they decided I could. During that whole time I’d been there, I’d not seen anyone from psych liaison, no one had done a mental capacity assessment. I repeatedly asked to see liaison psychiatry in the emergency department but was told I couldn’t see them until I was ‘medically cleared’ which the emergency department said would not be until at least the next day.”

Another woman, Rachel, who voluntarily attended a London A&E, was also searched, stripped of her belongings and told to wait without any communication or explanation.

She said: “I was taken to a room next to A&E and they were these bare rooms and had these security guards in the corridors and they didn’t explain why I was going there.

“A liaison nurse told me to go into this room which was bare. She said she had to search me, she didn’t really ask permission, she patted me down, even felt my breast, my jacket and bag were searched, and I had to take my shoes off, then my bag was completely emptied…

“My bag including my glasses, my phone, my pens, my papers and my keys to my flat. They were all taken off me and I was left with no belongings in this bare room. I was absolutely stunned and I couldn’t object to my bag being taken away from me – I didn’t really know what was happening.

“It felt like I was being detained… I was so traumatised. I wasn’t detained under the Mental Health Act; I didn’t give my consent.”

The identities of both patients have been changed, as they asked to be anonymous

Mental Health Matters is written by HSJ’s mental health correspondent, Rebecca Thomas. Tell her what you think, or about issues she could write about, by emailing her in confidence at rebecca.thomas@wilmingtonhealthcare.com or by sending a direct message on Twitter.