52 Med. Sci. & L. 1 (2012)

handle is hein.journals/mdsclw52 and id is 1 raw text is: 

Review Article

Emergency department as a 'place of safety': reviewing the use

of   Section 136 of the Mental Health Act 1983 in England

Dorothy C Apakama FRCS(Eng) FCEM
Consultant Emergency Medicine, Emergency Department, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road,
Coventry, West Midlands CV2 2DX, UK
Email: dotapax@googlemail.com

Section 136 provides the lawful authority for the removal, by the police, of the person to whom the provision applies, from a
place to which the public have access. There has been a longstanding debate as to the most appropriate place of safety
for these patients. The aim of this article is to review the literature and determine the ideal place for the detention and
assessment of these patients and clarify the responsibilities of the staff of the agencies involved in the detention. It concludes
that there is no single most appropriate place of safety for all groups of patients. Rather, there should be a range of options to
enable the assessment in the most suitable environment for individual cases according to their needs at the time.

Med  Sci Law 2012; 52:1 -5. DOI: 10.1 258/msi.2011.010154

Section 136 (S136) of the Mental Health Act 19831 (the 1983
Act) gives a police officer the power to remove persons who
appear to be mentally disordered from a public place to a
place of safety (POS). In practice, psychiatric units, police
stations and emergency departments  are commonly  used
in the UK, although the 1983 Act does allow other options.
  There has been a longstanding debate between the police
force and the emergency physicians as to the most appropri-
ate place of safety for these patients.2-5 Unfortunately, those
left in the middle of the debate are the junior doctors and
police constables, usually outside normal working hours.
Several studies have shown that about 77% of cases invol-
ving S136 take place between 18:00 and 09:00 hours.6
  A  study done  by  the Independent  Police Complaints
Commission  (IPCC)7 concluded that a hospital emergency
department   (ED) provides  a better environment   than
police custody for these patients. The Royal College of
Psychiatrists working  group8  recommends   that police
stations should only be used as the POS on an exceptional
basis and there should be sufficient places of safety in psy-
chiatric facilities to meet foreseeable local needs without
recourse to police stations as a convenient local option.
However,  in practice, where such facilities exist, they are
regularly full and the patients end up in the ED.
  Since the last review article on the use of S136 in the ED
(2002),9 there have been several amendments to the mental
health law, which  have implications for the use of this
power. The most recent review article6 focused on the socio-
economic status and demographics as well as the diagnostic
profiles of individuals detained under S136. The studies
indicated that S136  is inconsistently implemented and

monitored  across  the UK   and   that differences exist
between  rural and urban  areas. The review  revealed a
high prevalence  of schizophrenia, personality disorders,
mania and  drug-induced psychosis in individuals detained
under S136 and  an over-representation of black detainees.
This and similar studieso'11 have been dedicated to investi-
gating 'who' is detained under this section and 'how' it is
implemented.  This article, however, is about 'where' these
patients should be  detained  and  assessed. It aims to
provide evidence-based recommendations   as to the ideal
POS  for different patient groups.
  Joint training and  locally agreed  protocols as rec-
ommended   by the Code of Practice12 are needed for police
officers and health and social care staff. The aim is to clarify
the responsibilities of the staff of the agencies involved in
the detention to maximize safety of staff and ensure that
patients are treated with dignity and respect and according
to their needs. Where the ED is used as the POS, a quick refer-
ence guide for all staff is shown in the Appendix of this article.

Changes to the 1983 Act
Below  are the relevant 2007 amendments to the 1983 Act,
which may  impact on the use of S136.

(1) Single definition for mental disorder: Mental disorder is defined as
   'any disorder or disability of mind'. This extended definition
   encompasses people with personality disorder more readily
   than before. There is potential for increase in the number of
   people detained under the Mental Health Act generally and
   S136 in particular.
(2) Introduction of 'Supervised Community Treatment': Supervised
   Community  Treatment allows some individuals previously

Medicine, Science and the Law 2012; 52: 1-5

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