S136 Pathway Scenario: Intoxication pathway Police find Sarah in distress in a public place. She appears to be intoxicated and shows signs of having a possible mental health disorder. Police are in a position to consult with a mental health professional via local crisis line and therefore call the crisis line to get advice on the best course of action. Sarah is not known to services and has not been detained under s136 before. The Police decide on an alternative option for Sarah e.g. psychiatric decision unit (PDU) alcohol recovery unit or voluntary referral to A&E. Sarah is known to mental heath services and has been detained under s136 a number of times. The Police conclude that Sarah is in need of urgent care and decide to detain Sarah under s136. They call the London Ambulance Service (LAS) to attend the scene to convey Sarah to the appropriate care setting. A&E pathway HBPoS pathway LAS arrive within 30 minutes and medically screen Sarah. Sarah is deemed intoxicated and incapable and is taken to A&E with police in attendance. LAS are attending another call. Sarah is unable to stand due to intoxication. Officers seek authority from superiors to convey Sarah to A&E. They inform LAS of their decision. LAS arrive within 30 minutes and medically screen Sarah. LAS decide that Sarah should be taken to the nearest Health Based Place of Safety (HBPoS) because although Sarah is intoxicated she is still able to be assessed. LAS are delayed attending another call. Although Sarah is intoxicated she is still able to be assessed. Officers seek authority from their superiors to convey Sarah to the nearest HBPoS. They inform LAS of their decision. A&E accepts Sarah and after an initial screening by an A&E nurse and member of the psychiatric liaison team, a Registered Mental Health Nurse (RMN) is allocated to provide care and monitor Sarah whilst she is intoxicated and not fit to be assessed. The police confirm that a space is available at the local HBPoS via the Trust’s crisis line (which is able to provide both crisis advice and Health Based Place of Safety capacity). Sarah is conveyed to the facility. The RMN spends 4 hours monitoring Sarah, with regular check ins from A&E staff. Once Sarah has sobered up it is agreed that her mental health assessment can proceed and the psychiatric liaison team and A&E staff agree the next stages of Sarah’s care. The police arrive at the HBPoS site and two mental healthcare professionals are available to receive Sarah. The police gain access to the site within 15 minutes of arrival and within 30 minutes the s136 coordinator has accepted responsibility for Sarah’s custody and s136 papers are transferred. It is decided that Sarah’s mental health assessment will be carried out in A&E. A&E security staff are fully briefed and a senior ED clinical staff member approves the transfer of s136 papers to the A&E department. The s136 coordinator calls the local AMHP and Trust s12 doctor to attend the HBPoS to begin Sarah’s assessment. The legal responsibility of Sarah now lies with the A&E but it is mutually agreed that the police will remain in the department to provide the necessary support needed. Sarah is given an initial medical screening and physical health assessment by HBPoS clinical staff within 1 hour of arriving at the HBPoS, whilst waiting for the assessment to commence a brief alcohol intervention is carried out by clinical staff. The psychiatric liaison team contact the Trust s12 doctor and the local Approved Mental Health Practitioner (AMHP) to attend A&E to begin the assessment, they also ensure the relevant documentation is available to inform the assessment. The AMHP and s12 doctor arrive to carry out the mental health assessment and complete Sarah’s mental health assessment within 4 hours of Sarah arriving at the site, they then decide the next steps in her care. The s12 doctor arrives before the AMHP and is able to start Sarah’s assessment. The AMHP arrives shortly after and they work together to carry out the assessment. Following a thorough assessment, the AMHP and s12 doctor decide that although Sarah has a mental disorder, she does not require immediate psychiatric hospital admission. Following a thorough assessment, the AMHP and s12 doctors decide that although Sarah has a mental disorder, she does not require immediate psychiatric hospital admission. Sarah’s Crisis Resolution and Home Treatment (CRHT) team is contacted about her crisis presentation and an appointment is made for her that week. The AMHP has responsibility for making the community-based care arrangements but the psychiatric liaison team will ensure information collected throughout the assessment is sent onwards and received by the CRHT team within the next day. Sarah’s CRHT team is contacted about her crisis presentation and an appointment is made for her that week. The s136 coordinator has responsibility to send the referral letter providing information gathered throughout the assessment and ensuring it is received by the CRHT team within the next day. Sarah is discharged from the s136 as soon as the care arrangements are in place, not exceeding the maximum period of detention of 24 hours. Sarah is discharged from the s136 as soon as the care arrangements are in place, not exceeding the maximum period of detention of 24 hours.

S136 Pathway Scenario: Transferring the patient from A&E to HBPoS Police Officers come across Liam (aged 15) behaving strangely by the O2 Arena in Greenwich. He does not respond to the police when they try to ascertain whether he is ok and he is bleeding from an open wound on his arm. Police are in a position to consult with a mental health professional via local crisis line and therefore call the crisis line to get advice on the best course of action. The Police decide that Liam is in need of urgent care and decide to detain him under s136. They call LAS to attend the scene to convey Liam to the appropriate care setting. HBPoS pathway A&E pathway The police arrive at the HBPoS site and two mental healthcare professionals are available to receive Liam. The police gain access to the site within 15 minutes of arrival and within 30 minutes the s136 coordinator has accepted responsibility for Liam’s custody and s136 papers are transferred. LAS arrive within 30 minutes and medically screen Liam. LAS decide that Liam’s injury needs to be sutured and take Liam to A&E with police in attendance. LAS are attending another call. Officers seek authority from superiors to convey Liam to A&E so that his injury can be further assessed. They inform LAS of their decision. The s136 coordinator calls the local Approved Mental Health Practitioner (AMHP) and Trust S12 doctor to attend the HBPoS to begin Liam’s assessment. The AMHP arranges the second S12 doctor. Liam arrives at A&E and is triaged by A&E clinical staff who provide an initial physical assessment and arrange any necessary investigations. The psychiatric liaison team are notified at this stage of Liam’s arrival. Liam is given an initial medical screening and physical health assessment by clinical staff within 1 hour of arriving at the HBPoS. Whilst A&E staff assess Liam’s injuries the psychiatric liaison team respond within 1 hour to carry out an initial risk assessment to ensure Liam’s immediate mental health needs are met. The AMHP and s12 doctor arrive to carry out the mental health assessment, at this point they believe inpatient care is needed and the AMHP calls the second s12 doctor. The psychiatric liaison team and A&E staff discuss the next stages of Liam’s care, including the predicted timeframes for suturing Liam’s arm and the timeframes for the mental health assessment. The AMHP and s12 doctors complete Liam’s mental health assessment within 4 hours of Liam arriving at the HBPoS and they decide the next steps in his care. It is agreed between teams that once the suturing of Liam’s arm is completed he will be able to be transferred to the nearest HBPoS for the mental health act assessment. A&E staff ensure that Liam’s physical health care is expedited to ensure the mental health assessment is able to commence promptly at the closest Health Based Place of Safety (HBPoS). It is decided that Liam needs to be admitted for further treatment and he agrees to be voluntarily admitted to a Tier 4 Children and Adolescent Mental Health Service (CAMHS) unit. The police confirm that a space is available at the local HBPoS via the Trust’s crisis line (which is able to provide both crisis advice and HBPoS capacity). It is recognised that Liam is a patient of a North West London Trust however a South East London HBPoS (closest to the A&E) agrees to receive him. The bed manager at the mental health trust where Liam has been assessed arranges a Tier 4 CAMHS bed for Liam near his home in North West London. Whilst Liam is being treated by A&E staff, the psychiatric liaison team arranges hospital transport to convey Liam to the SEL HBPoS. As Liam is a minor and has received sedation, it is decided that a member of clinical staff should travel with him to the HBPoS. The s136 coordinator has responsibility to send the transfer letter providing information gathered throughout the assessment and ensuring it is received by the CAMHS ward team within the next day. Liam and the A&E staff member are collected from A&E within 1 hour. Police continue to stay with Liam during conveyance given he is still the legal responsibility of the Police. The s136 coordinator arranges transport to convey Liam to the ward (with approval from the AMHP). Liam is collected from the HBPoS within 1 hour.

S136 Pathway Scenario: Taken to A&E and stays for observation Police are called to a public park where Shamima was found unconscious by a member of the public. The police are able to rouse Shamima but she is unable to stand and is talking about wanting to end her life. The police find an empty bottle of paracetamol and suspect that Shamima may have taken an overdose. Police are in a position to consult with a mental health professional via local crisis line and therefore call the crisis line to get advice on the best course of action. Shamima is not known to services but has demonstrated that she is feeling suicidal. Shamima is unwilling to go to A&E voluntarily. The Police conclude that Shamima is in need of urgent care and decide to detain her under s136. They call LAS to attend the scene to convey Shamima to the appropriate care setting. LAS arrive within 30 minutes and medically screen Shamima. LAS decide to take Shamima to A&E. LAS are attending another call. Officers seek authority from superiors to convey Shamima to A&E. They inform LAS of their decision. Shamima arrives at A&E and is triaged by A&E clinical staff who provide an initial physical assessment and arrange any necessary investigations. The psychiatric Llaison team are notified at this stage of Shamima’s arrival. Whilst A&E staff assess Shamima’s physical health needs, the psychiatric liaison team respond within 1 hour to carry out an initial risk assessment to ensure Shamima’s immediate mental health needs are met. The psychiatric liaison team and A&E staff discuss the next stages of Shamima’s care, including the predicted timeframes for physical health investigations, treatment and timeframes for the mental health assessment. It is confirmed that Shamima needs to be kept in hospital for observation. The psychiatric liaison team and A&E staff agree that Shamima’s mental health assessment can proceed in A&E and a senior clinical staff member approves the transfer of s136 papers to the A&E department. The psychiatric liaison team contact the local Approved Mental Health Practitioner (AMHP) and Trust s12 doctor to arrange for them to attend A&E to begin the assessment, they also ensure the relevant documentation is available to inform the assessment. The s12 doctor arrives before the AMHP and is able to start Shamima’s assessment. The AMHP arrives shortly after and the team work together to agree the next steps in Shamima’s care. Shamima feels better after a while but admits to lots of problems. The AMHP and s12 doctors agree that she does not need inpatient care but that Shamima requires additional support. The AMHP arranges for Shamima to be referred to the home treatment team at her local mental health trust, they agree to see Shamima the following day. The AMHP has responsibility for making the community-based care arrangements but the psychiatric liaison team will ensure information collected throughout the assessment is sent onwards and received by the home treatment team within the next day. Shamima is discharged from the s136 as soon as the care arrangements are in place.