A parliamentary written answer about creating an autism marker on the Police National Computer (PNC) was recently answered:
Lord Touhig (Labour)
To ask Her Majesty’s Government what progress has been made in considering whether police marker systems used to identify those with mental health and learning difficulties can be extended to those with autism as proposed in the report Think Autism.
Lord Bates (Conservative)
Work is continuing to establish whether a separate marker, specifically for autism, can readily be added to the Police National Computer in addition to the existing mental health marker, and to assess potential impacts on police force IT systems.
A follow-up written answer clarified the implementation plan:
Lord Touhig (Labour)
To ask Her Majesty’s Government, further to the Written Answer by Lord Bates on 5 February (HL4542), whether there is a deadline for completing work to establish whether a separate marker, specifically for autism, can be added to the Police National Computer […], whether the current police information technology systems are capable of accommodating an additional marker, specifically for autism, to be added to the Police National Computer.
Lord Bates (Conservative)
For the purposes of speed of implementation it is proposed to use an existing marker to encompass cases of autism rather than developing a specific marker, which would require further significant work and assessment. These proposals are expected to be considered by the Police National Computer Board within the next month.
The National Autistic Society’s (NAS) Policy & Parliamentary team provided a note titled Further information on Government proposals to establish a marker for autism on the Police National Computer. I am copying its content below and interspersing with some comments:
What is proposed?
A Police National Computer (PNC) record is created for anyone who is charged with an offence or receives a fixed penalty notice, community-based service, or caution. This may be for first time or continued offending.
This is incorrect. ‘The PNC holds details of people who are, or were, of interest to UK law enforcement agencies’. A PNC record is created at arrest and is retained until the individual becomes 100 year-old (if there are several dates of birth on record, the first one is used). See Notes on the Police National Computer for more details on the PNC.
Current Government proposals are to include a marker on these records that alerts criminal justice workers to a person’s autism. The Government’s proposal is to record autism within the “AT” marker, rather than to take longer creating a new marker: The AT marker signifies ‘Ailment’ and will remain on the record for the life of the specific record (e.g. being acquitted or the record being expunged). There is room for 60 text characters (max) to accompany the marker, e.g. “has autism, needs support”.
The NAS persists in its use of the offensive person first terminology (‘has autism’). Autism is an integral part of who we are and how we experience the world. Identity-first language should be preferred (’is autistic). Someone does not have Englishness or jewishness or left handedness, or autism, etc. One is English or jewish or left handed or autistic. This page has a good explanation of this semantical issue.
The NAS recognises that the use of the phrase “Ailment” is unfortunate. However, this will mean that information about someone’s autism can be recorded more quickly. It is important that criminal justice professionals receive training so that they can interpret this marker, know about the nature of autism and make suitable adjustments. To this end, the NAS is working with the Cross-Government group on autism and the criminal justice sector to develop training resources for professionals.
The NAS also believes that, while the recording of autism under the AT marker will provide a quick solution in the short term, the relevant authorities should continue to look to create a separate, more appropriate, marker that could record autism (and potentially other non-medical or non-mental-health conditions).
Even though the NAS finds the current proposal ‘unfortunate’ and short term, its policy advocates for the creation of a ‘marker that could record autism’ (and potentially other neurodivergences).
This is very concerning, as it is advocating for what will effectively be a database of autistics for policing purposes. That the records have to already exist to add such a marker is not as much a safety as it may look; one only has to remember the claims that Police ‘have made arrests just to get people on to the DNA database’. Such a database would criminalise and stigmatise autistics. Being autistic is not criminogenic; if anything it may increase the risk of being victim of crime.
Also there are many autistics who have not yet realised they are autistics. Would this marker apply solely to autistics having followed the medical pathway and been medically diagnosed? If the criminal justice system (CJS) became over reliant on such a marker, it would create the additional risk that the many autistics not having the marker would not be dealt with adequately.
Another unaddressed issue is what criteria would be used to decide to set such a marker for an individual? Does this imply that autistics would be forced to disclose their autism? Whether and when to disclose is an an individual right. This right to choose cannot be so lightly ignored.
What could be useful to record in a database accessible to emergency call handlers is communication needs, e.g., whether some one uses BSL as first language, is unable to make voice calls, may need an independent advocate, etc. That would still be useful only for those on this database so is a very limited solution.
What does this mean for a person with autism?
For most people with autism, this will have no effect at all as it only adds a marker to existing PNC record (i.e. there must have been a caution, charge or sanction).
If it will have no effect for most autistics, then what is the point of advocating for such a marker? What is the point of creating an ineffective, criminalising and stigmatising marker, albeit on a pre-existing PNC record? There are better solutions to improve the actions of those in the criminal justice system towards all autistics.
This PNC project is designed to make it easier for the police to know if a person has been diagnosed with autism so that they know they may need to make changes to their usual practices and make sure they are explaining what is happening so that it is understood. We believe that, on the whole, this could be useful for police and may help a number of interactions between people with autism and the police from escalating.
The NAS has heard of situations where, for example a confrontation between police and a person with autism has escalated because of the shouting of confusing/mixed instructions. While the marker will be limited to people who already have a PNC record, one possible virtue of the marker is that police would be alerted to a person’s autism and know to approach an arrest differently. This cannot replace appropriate training of criminal justice professionals, but would be intended to help those with training identify appropriate responses much more quickly
Good training is indeed essential. Some researchers, police officers and the Home Affairs Committee also agree. Police need to understand that atypical behaviour is just a different behaviour and not a sign of criminality. Some of the reasons given by the police for finding my behaviour suspicious and wrongfully arresting me were that I had avoided eye contact with them (a failure to interpret social cues appropriately) and was wearing a jacket allegedly too warm for the season, both of which are common autistic behaviours.
Training for the police and others in the criminal justice system on common autistic behaviours and sensory issues would be particularly helpful.
How can this information be used?
Given the sensitive nature of the information, it is vital that it is not used improperly – especially to stigmatise people with autism or to fuel misconceptions about them. We have asked criminal justice representatives how the proposal means the information within the marker will be used. This section summarises their response.
This is nice wishful thinking, but there are examples of the PNC, including information of a sensitive nature such as DNA profiles and photographs, used improperly. For an innocent to become an honorary criminal by being on a police database is stigmatising. If there’s an autism marker, it would be surprising for it to never be used improperly.
In data protection terms this information is classed as sensitive personal data so permission of the individual concerned should always be sought by any non-police agency seeking inclusion of relevant marker on PNC.
Police does not seek consent for inclusion of information on the PNC. If the information is to remain under the control of autistics, then a much simpler mechanism is to carry a card briefly explaining that one is autistics and possibly including some basic interaction advice. If one cannot talk to explain they are autistic, they may show their card, and if handcuffed, the police will find the card when searching the individual. The police must treat all who have special needs appropriately whether these are expressed verbally or with a card. And an autism alert card can be used in other settings as well.
As regards to data protection, databases have incorrect information, information can leak (or become lost on a train) and databases can be used for surveillance. Not entering additional information, especially in a police database, avoids all these issues. (After the police decided to take no further action in my case, they forgot to update the PNC accordingly for many months, in breach of the Data Protection Act. This is not a theoretical issue.)
The marker would be present for protective purposes. Suggested examples of (policing) decisions which it would usefully influence:
- Police contact on the street with someone presenting in a way that is perceived by those police as unusual - a PNC “body check” (police speak for a record check based on name and date of birth) would result in the PNC operator disclosing existence/nature of any warning markers to the officer and this could influence the outcome of the contact, possibly avoiding arrest.
- Support measures put in place for previous offenders who are victims or witnesses at a later date.
- Where a criminal offence has apparently taken place, awareness that the suspect has autism would bring a number of other factors into play, i.e. necessity to call police healthcare provider to triage/assess fitness for further process and interview, ask for Appropriate Adult (AA) service, information as to rights and entitlements provided in presence of AA, provision of solicitor, arrangements for interview format to be adapted so appropriate for autism.
- Police/CPS decision on criminal justice outcome would be appropriate to nature of offence and needs of the individual and may include diversion to aftercare service.
- For courts and prisons it is expected that this would result in similar protective arrangements - including extra vigilance in a prison context to ensure that the prisoner is appropriately supported as vulnerable and not abused.
The NAS’ position
The NAS believes that the central issue for improving experiences of the criminal justice sector for people with autism is ensuring that all professionals have a good knowledge of autism and the changes that they need to make to practices and environments. We are currently working with the College of Policing to improve training for new police recruits and pushing for more training for other professionals.
Improving training is a positive step. Awareness is essential, but not sufficient. Acceptance of neurodivergences is what is needed.
In order to ensure that the right changes can be made, it is vital that the police, or other criminal justice sector professionals, know that someone has autism as soon as possible. There are a number of ways that this can be achieved: e.g. autism alert cards, encouraging people to declare their autism without fear of prejudice, improving training so professionals can identify the signs. A marker on the PNC is one other way that this could happen.
We believe that there are important safeguards that must be included, to ensure that sensitive data is used appropriately. Professionals must be sufficiently knowledgeable about autism to know that having autism is not an indicator of criminality or guilt. The marker should only be used in ways that will allow a person with autism the same protection of the law and access to justice as any person.
It is discriminatory and wrong for the police to keep markers which have nothing to do with criminality on categories of individuals for most of their lives. Police keeping tab on innocent inviduals is typical of a police state, not of a liberal democracy. Having an autism marker on the PNC will criminalise autistics. As was expressed in the European Court of Human Rights judgment in S. and Marper v. the UK: ‘Weighty reasons would have to be put forward by the Government before the Court could regard as justified such a difference in treatment of the applicants’ private data compared to that of other unconvicted people.’
By focusing on a marker identifying autistics, this discriminatory approach, rather than addressing the root causes of how traumatic encounters with the criminal justice system too often are for autistics, further legitimises the current societal attitude of blaming autistics for their poor treatment.
A much better solution to the problem this tries to address is two-fold: training of those in the criminal justice system and autism card schemes. Voluntarily carrying a card can help an autistic encountering the police to clarify that some of their behaviour may be atypical. A card is fully under the control of the individual. It is a helpful communication tool, not an ID card or get out of jail free card. And such cards can be used in other situation where communication may be difficult.
The police must serve all of society with respect and humanity. Autistics deserve equal treatment and the forced disclosure of our neurology to ensure ‘equality’ cannot be a requirement. The police need to be aware and more accepting of all neurodivergences, including of autism. An increased acceptance that many experience the world differently, would be of benefit to more than just autistics.
Hopefully the NAS will fully consider the many problems and risks of such a marker, review its policy and use its influence to help stop this proposal going any further.
This post was written in collaboration with Kabie Brook, chairperson of the Autism Rights Group Highland (ARGH). ARGH has designed an autism alert card available to all autistic people, children or adults, across the UK and carried by several hundreds autistics.
Some other recent parliamentary debates and written answers about autism:
The Discovery programme on BBC World service broadcast an episode on the throwaway society on 2015-02-16:
Hundreds of millions of computers, mobile phones and televisions are thrown away every year around the world. In this week’s Discovery Gaia Vince will be looking at the reasons behind this rapidly growing mountain of electronic waste and asking, who is responsible? The manufacturers or the consumers? When our gadgets break, maybe we should just be repairing them. And Gaia attends a party where people are fixing stuff for themselves.
The half hour programme can be listened to on the BBC Radio Player.
Some of the interviews were recorded at a Hackney Restart Party. My interview starts at 19:21.
Bootnote: Other blog posts about The Restart Project:
For the past two years I have been attempting to uncover what happened during two critical incidents that occurred at the River House facility operated by the South London and Maudsley (SLaM) NHS Foundation Trust on 2012-10-01. I eventually exposed that 48 Metropolitan Police Service (MPS) officers were deployed and that four TSG officers drew their Tasers on the mental health ward.
Using the Freedom of Information Act, I got SLaM to initially publish a redacted summary report and then to unredact it, fully. This revealed it was hiding a full report. Using that information, I got it to publish an extensively redacted version of the full report. After an internal review in which SLaM found it was justified to do all these redactions on health and safety, and third party personal data, last week, the Information Commissioner's Office (ICO) disagreed and decided against SLaM:
South London and Maudsley NHS Foundation Trust
21 January 2015, Health (NHS)
The complainant has requested a copy of an investigation report that was commissioned to investigate an incident that occurred on a ward at the South London and Maudsley NHS Foundation Trust (the Trust) in late 2012. The Trust initially relied on the future publication exemption (section 22) in FOIA to withhold a version of the report. Upon its publication, parts of the report were withheld under the health and safety (section 38) and third party personal data (section 40(2)) exemptions in FOIA, although these were later released to the complainant. However, during the course of the Commissioner’s investigation it became apparent that the Trust had only considered a summary of the report rather than a version containing the complete findings. A further partial disclosure of the complete report was made with the remaining information withheld under sections 38(1)(b) and 40(2) of FOIA. The Commissioner has found that section 40(2) but not section 38(1)(b) of FOIA is engaged. He therefore requires the disclosure of the information to which section 38(1)(b) has been applied. The public authority must take these steps within 35 calendar days of the date of this decision notice. Failure to comply may result in the Commissioner making written certification of this fact to the High Court pursuant to section 54 of the Act and may be dealt with as a contempt of court. [Emphasis added]
FOI 38: Upheld FOI 40: Partly upheld
Here are my previous posts about this incident:
SLaM has to publish an unredacted version of its full report that complies with the ICO's decision by 2015-03-25.
The Protection of Freedom Act 2012 introduced more restrictive rules about the retention of DNA profiles of individuals on the National DNA Database (NDNAD) including the deletion of the DNA profiles of most individuals who are not charged (No Further Action) or acquitted. This was a change welcomed by activists who had been campaigning that keeping tabs on innocents should not happen in a liberal democracy and that it does not make policing more efficient (adding hay to the hay stack makes finding the needles harder). What would have increased the crime detection rate would have been to fund for more DNA profiles from crime scenes to be added.
As of 31 March 2014, the National DNA Database held 5,716,085 DNA profiles from individuals down from 6,737,973 a year earlier, and 456,856 DNA profiles from crime scenes up from 428,634 a year earlier. In 2013-14, 1,384,905 DNA profiles from individuals were deleted from the database. Of these, 1,352,356 of these were deleted under the provisions of PoFA; 31,690 profiles taken by Scottish forces were deleted under Scottish law. A further 6,837 crime scene profiles were deleted because the crimes had been solved.
I wrote nearly three years ago:
It is a success for all the privacy activists and victims who campaigned to restore the presumption of innocence and the rehabilitation of offenders having been convicted of a minor crime. GeneWatch UK –as an indefatigable organisation at the forefront of the campaign to change the law to make the National DNA Database much smaller and more carefully controlled, and to safeguard privacy and rights without compromising the use of DNA in fighting crime– deserves much credit in this success.
Last month the government eventually agreed with what we had said all along. Lord Bates, Lords Minister and Minister for Criminal Information, Home Office in his ministerial foreword to the National DNA Database: annual report, 2013 to 2014 recognised that:
The reduction in profiles held from innocent people has not led to any reduction in the number of matches the database produces. In the quarter from 1 April to 30 June 2014, the database produced 37 matches to murder, 127 to rapes and 6,111 to other crime scenes. In the same quarter of 2013, when the old system for retaining DNA was in effect, it produced 37 matches to murder, 103 to rapes and 6,141 to other crime scenes.
Chris Sims, Chair, National DNA Database Strategy Board Chief Constable, West Midlands added:
The NDNAD match rate on loading a crime scene profile reached 61.9% in 2013–14. This was the highest annual rate yet and shows the success of the NDNAD in detecting crime and protecting the public.
The NDNAD Strategy Board showed some surprise at this outcome at its September 2014 meeting, but could not find any error in the draft annual report!
4.6 MC presented a draft of the National DNA Database Strategy Board’s Annual Report for 2013–14 (Paper 4.1) to the Board. He thanked Carl Jennings for his hard work on the report. He said that this was the first report since the implementation of PoFA. The proportion of profiles from innocent people had fallen from 50% to 3%. He reported that the number of profiles on the database had fallen from 7.2 million to five million but that the match rate had had in fact risen slightly from 59% to 62%. He had checked this with KF and they could not find any errors with the figures. JA said that the increase in match rate was not expected; in fact, a decrease had been anticipated. She asked if the number of crime scene profiles had reduced. MC said that the report would be published as soon as the Board were content. CS added that it was good that we were near publication.
4.7 CS asked if we had got the chronology on the deletion of samples correct and MC confirmed that we had. Batches of deletions took place in fairly short timescales (for example over a weekend). CS said that we needed a proper review of PoFA implementation and MC added that any analysis of implementation must be independent and not carried out by the police or the Home Office. CH added that such a review would need ministers’ co-operation as well as funding and an appropriate experimental design. AP said that the scientific design committee could input into any such review.
Blanket and indiscriminate surveillance is not the solution. It is neither necessary nor appropriate.
Retention periods for DNA profiles and fingerprints (as presented in the annual report).
|Occurrence||Fingerprint and DNA Profile Retention|
|Minor offence – arrested or charged||None – but speculatively searched|
|Qualifying offence* – arrested not charged||None, but in exceptional cases on application to the Biometrics Commissioner, three years retention may be authorised, plus two year extension by court|
|Qualifying offence* – arrested and charged||Three years plus possible two year extension by court|
|Minor offence – Penalty Notice for Disorder||Two years|
2. Convictions (include cautions, reprimands and final warnings):
|Occurrence||Fingerprint and DNA Profile Retention|
|Under 18 – Convicted of a minor offence||First conviction: five years (plus length of any custodial sentence), or indefinite if the custodial sentence is five years or more.|
|Under 18 – Second conviction||Indefinite|
|Under 18 – Convicted of a qualifying offence*||Indefinite|
|Adult – Convicted of an offence||Indefinite|
*Qualifying offences are serious violent or sexual, terrorism and burglary offences.
Where an individual has more than one arrest on their record, the longest retention period will be applied.
Should police officers behave differently with autistic suspects? Two recent commentaries support the changes I suggested in my written evidence to the Home Affairs Committee.
Researchers found that conventional police interview techniques are not effective for people with autism:
Police find interviewing and interacting with witnesses and suspects with autism a real challenge, a study has revealed - highlighting that the ways officers have been taught to interview are at odds with what is needed in these situations. Existing interview techniques tend to focus on open questions, only later narrowing down to closed questions, but research shows that people with autism may need focused questions from the outset.
The Economic and Social Research Council (ESRC)-funded research studied what does, and does not, work when police interview people with autism. The researchers - Dr Katie Maras, University of Bath, and Dr Laura Crane, City University London - are calling for better training of police and criminal justice professionals as, at present in the UK, these groups currently have no standard compulsory training about autism. […]
My experience of the police interviewing process, as described in my evidence, matches this research:
10. As I was innocent and did not know any better at the time, I made the mistake to refuse to call a solicitor. During the police interview, one question particularly bothered me. The interviewing officer after asking me questions about my laptop such as 'has it got anything on there about public underground?' and 'has it got anything on there about plans for any terrorism act?', asked 'has it got anything on there that might be construed as causing a public nuisance?'. The correct answer would have been 'yes' as I have a word processor, an email client, etc that could all be useful to a terrorist and most likely can be construed to be of use for anything including causing a public nuisance. However, I also realised that answering the positive would not be helpful to me and challenged the question when the investigating officer just wanted answers.
An obvious way forward to make police encounters less damaging to autistics would be to improve training. Inspector Michael Brown, who is on secondment to the College of Policing as Mental Health Coordinator, recommends on his Mental Health Cop blog to have autism awareness training for police officers:
[…] I've argued before that I see the point of specific autism awareness training for police officers because we know that where officers deal with incidents involving someone with autism there could be considerations that wouldn't necessarily apply to other situations, if they can be accommodated. I'm not sure if that could be said of all of the above conditions, however. Would it matter to the policing of an emergency mental health incident whether someone who appeared to be in distress was psychotic because of schizophrenia or because of bipolar or because of Addison's disease? Probably not. […]
These two commentaries support the recommendations I made to the Home Affairs Committee:
12. An essential recommendation would be for all front-line police officers to receive some training about the autism spectrum. This training ideally would involve those on the autism spectrum. I understand that a few police officers have had sessions with the Asperger London Area Group (ALAG). This training should be made more generally available.
13. At the very least, front-line officers should read the ACPO-endorsed Autism: a guide for criminal justice professionals publication of the National Autistic Society.
14. With such training it is hoped that police officers realise that a behaviour different from that of a neurotypical is just different rather than suspicious; consider hyper- and hypo-sensitivities that the public they interact with may have; and use clearer interviewing questions.
Restarter Profile: Meet David
Tell us a little about yourself.
I am known as either David or Panda. I moved to London from Paris twenty-one years ago. I have studied computer science and criminology, and worked as a software developer, a technologist and a journalist. I am autistic and have been described as ‘calm, almost too calm’.
When did you start repairing electronics and electricals?
Before the web had been invented. A lot of my early repairs were telecoms related: RS232 cables, modems and phones, and computers as well.
Why do you attend Restart Parties?
To empower others to regain control of their devices. For more than thirty years I’ve been demystifying new technologies and software development, initially, and how to reclaim our civil liberties, later. The collaborative repairing going on at Restart Parties are occasions to demystify repair and to empower participants to fix their electronic and electrical devices. It is for this transformative process, when people realise that many repairs are accessible to them, that I am involved with the Restart Project.
What is your favourite kind of repair?
The variety is interesting, but what is most gratifying is when someone arrives hoping for a free fix and leaves having fixed their device mostly on their own. It is the process of discovery, when they realise that they are already knowledgeable: that if they have changed a fuse they likely understand the need for electric continuity; that if they have ever touched a lit lightbulb they likely realise that electric devices get hot. Fixing their device is a small step from that knowledge: when a device stops working, first steps are to check that everything is still connected, that electricity flows, and that there’s no dust or crumbs blocking any fan so the heat is not trapped inside. The next realisation is that some simple tips go a long way: how not to end up with a pile of screws, use a pill box or an egg carton to store them so it’s easy to find which screws are used at which step when time comes to reassemble things. The skills needed for such repairs are a lot of common sense, some limited experience (learnt in the process), good research skills and access to a few tools.
What do you do when you are not Restarting?
Learn, research, occasionally write. Check on the welfare of the detained persons by making unannounced visits to the custody suite of police stations. Write (too many) Freedom of Information requests. Walk.
What frustrates you (in life)?
Injustice. Noise. Surveillance. Crowds. Deaths in custody. Cars. Waste.
What gets you out of bed in the morning?
Restart Parties, Qi Gong, police custody visits, mornings of mindfulness, conferences. Though mornings are difficult and best avoided.
What’s the first thing – one material thing – that you could not live without? (besides oxygen, food, water, and shelter and medical care)
In this weather, a hat.
Share something cool with us [preferably a link]
Bootnote: Read an earlier post about my experience of becoming a restarter.
After my unlawful arrest in July 2005, I complained to the Independent Police Complaint Commission (IPCC) and then appealed the outcome of the supervised investigation. After deciding not to uphold my appeal, the Independent Police Complaint Commission (IPCC) closed my case file seven years ago. On 2014-06-19, the seventh anniversary of its final correspondence about my appeal, the IPCC was due to delete the electronic content of my case file and destroy its paper content.
When reminding the IPCC of this deadline, I requested to witness the occasion. This was refused:
Unfortunately, it is not possible for you to witness either the destruction of the hard copy file or deletion of the electronic file but we will send you confirmation of their destruction once this has been done.
At a time when the IPCC is trying to regain the trust of the public it is disappointing that such requests cannot be accommodated. However on 2014-06-20, IPCC's Records & Archives Manager confirmed it had all been done:
I am pleased to confirm that the documents held in the electronic file of your case were deleted yesterday morning. I confirm that four paper files were also destroyed at the same time.
I attach a spreadsheet detailing the electronic documents that were deleted. I am unable to list the contents of the paper files as we do not maintain an index of each paper document destroyed, only the fact that the file has been destroyed. Included in the spreadsheet is reference to the destruction of the 4 paper files.
The attached spreadsheet listed the creation date, record number, title and container title (the case reference number) of 32 electronic documents that had just been deleted and the box numbers of the four paper files that had been destroyed.
I found it difficult to verify whether the spreadsheet listed all the documents I knew the IPCC held. Some of the dates did not match that of the documents I had obtained with a subject access request and most of the documents I had did not have titles. I was concerned that the IPCC might still be retaining some documents and requested a review of the deletion process. The IPCC's Records & Archives Manager explained on 2014-06-27:
In 2006 the use of a Electronic Document Records Management System (EDRMS) was in its infancy at the IPCC. At this time the majority of information was filed in paper files. Your case was allocated a case number 2006/007520 and documents for your case, whether in electronic or hard copy format, were filed against this number. The whereabouts of paper files were also recorded onto the EDRMS.
Electronic documents were either scanned or saved directly to the case file and dated with the date that they were added to the system, not the date of the document. As an example of this, the document cited in your email "Final Report Minute - Supervised Investigation' from the Casework Manager to the Commissioner dated 23/11/2006," is shown on line 18 in the spreadsheet as FR minute and dated 4 December 2006.
There were four paper files allocated to your case file number, these were files of some substance I am unable to say what documents were contained in the files as they have now been destroyed.
Following receipt of your email, I have carried out a search on the EDRMS which reveals that there are no electronic or paper files still in existence for this case.
Although all documentation is filed to the appropriate case file, in order to allay your concern that some documents have been inadvertently retained, I have spoken to the casework manager who had conduct of your case and to the commission secretariat to ensure that they have no documents relating to your case in their possession. In both cases they confirmed that they do not have any documents.
I am therefore able to confirm that all documents relating to your case have been destroyed in accordance with our retention policy.
Even after this apparently thorough review, I had some remaining concerns as to whether the searches may have missed documents with the case file reference mistyped or misspellings of my name (such typos were present in some of the documents). This had been considered:
I did carry out some searches using variances of both your name and the case number. These were done both on my initial search and the further search carried out last week.
It would have been easier to allow me to witness the deletions and destructions as initially requested.
I have two ongoing complaints with the Information Commissioner's Office (ICO) about how the South London and Maudsley (SLaM) NHS Foundation Trust and the Metropolitan Police Service (MPS) are both responding to some of my Freedom of Information requests. There's little visibility as to when further disclosures, prompted by the ICO's caseworkers, are made by SLaM and the MPS. Soon after SLaM sent me an over-redacted 105-page report into incidents at the River House mental health secure unit, I received four Taser use forms from the Metropolitan Police Service. (Both complaints are ongoing as the SLaM report is clearly over-redacted and the MPS have not yet addressed the non-location of its incident management log.)
These new disclosures are directly related to the second section (paragraphs 15 to 23) of my Evidence to the Home Affairs Committee's inquiry into policing and mental health submitted last month and are relevant to this inquiry. I sent to the Home Affairs Committee a supplementary evidence about SLaM's disclosure of its 105-page report earlier this month, and copied below is a further supplementary evidence (also published on the Parliament's website as PMH0044) about the MPS eventual disclosure of the four Taser use forms:
 PMH0021 David Mery - written evidence (PDF): http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/home-affairs-committee/policing-and-mental-health/written/9174.pdf
MPS disclosure of the four Taser use forms: https://www.whatdotheyknow.com/request/river_house_2012_10_01_critical#incoming-530359
Direct links to the four forms: https://www.whatdotheyknow.com/request/193137/response/530359/attach/3/Redacted%20Taser%20Use%20MPS%2002.10.12%20287.12.doc.tif.pdf, https://www.whatdotheyknow.com/request/193137/response/530359/attach/4/Redacted%20Taser%20Use%20MPS%2002.10.12%20291.12.doc.tif.pdf, https://www.whatdotheyknow.com/request/193137/response/530359/attach/5/Redacted%20Taser%20Use%20MPS%2002.10.12%20292.12.doc.tif.pdf and https://www.whatdotheyknow.com/request/193137/response/530359/attach/6/Redacted%20Taser%20Use%20MPS%2002.10.12%20294.12.doc.tif.pdf
 An independent investigation into the circumstances surrounding two separate but related incidents involving Norbury patients on Spring Ward on the night of 1st October 2012 (Final Report - Summary): https://www.whatdotheyknow.com/request/164330/response/496004/attach/3/RH%20Report%20Oct12%20unredacted.pdf
 An independent investigation into the circumstances surrounding two separate but related incidents involving Norbury patients on Spring Ward on the night of 1st October 2012 (Final Report): http://www.slam.nhs.uk/media/255726/slam_rh_incident_underlying_detail_redacted_140528.pdf
 Minutes of meeting of Lambeth's Health and Adult Services Scrutiny Sub-Committee (Item 5), 2012-10-23: http://moderngov.lambeth.gov.uk/mgAi.aspx?ID=20256
Last month I submitted some Evidence to the Home Affairs Committee's inquiry into policing and mental health. On 2014-05-28, the South London and Maudsley (SLaM) NHS Foundation Trust sent a further response in relation to my complaint to the Information Commissioner's Office and I consequently sent the supplementary evidence, copied below, to the Home Affairs Committee (also published on the Parliament's website as PMH0043):
As mentioned in paragraphs 17 of my evidence I have an ongoing complaint with the Information Commissioner’s Office about the cover up of the South London and Maudsley (SLaM) NHS Foundation Trust concerning incidents at the River House mental secure unit. There has been some progress in this regard which should be of interest to the Home Affairs Committee.
As a response to this ongoing complaint, SLaM has now published a heavily redacted version of its full 105-page report (pdf) into these incidents. [In case this redacted report is updated or removed, a copy, as originally published, is available here (pdf).]
This report is distressing as it is still heavily redacted with snippets of great concern appearing without the original context. I have asked the Information Commissioner’s Office to check the redactions are valid as even without having access to the full document, many redactions are clearly excessive and not justified by the claimed exemptions (these exemptions can be read in SLaM's letter (pdf). [This letter is part of this Freedom of Information request.])
For instance, on p. 19 one interviewed staff is of the opinion that these incidents could have been avoided and that none of the 48 police officers that attended River House that night should have been deployed: ‘[…] it was possible to foresee what would happen, once a decision was taken to [redacted]. In the opinion of [redacted], the situation could have been pre-empted and the police should not have been called.’
However, only a few pages later on p. 23 there are both mentions of the seriousness of how the incident developed and the confusion between staff and the Trust about it: ‘Comment: several staff referred to incident 1 as a hostage situation, whereas according to the Trust Policy (Major Incident Protocol), it is defined as a riot.'
A clear example of the further poor attempt at a cover-up can be seen on p. 31. Most of the paragraphs describing the details of 'Incident 2' are redacted, however we already know from the 12-page summary report (link in footnote 11 in my evidence), and the repeated paragraph in the executive summary (p. 3), that 'In the second incident which occurred at approximately 0250, one patient challenged staff with regard to decisions which had been taken about the management of the four patients involved in the first incident. He accused them of discrimination, believing that there had been a racist motive and that staff had assisted the police to pursue this line of action. He threatened to kill staff and one of the white perpetrators, who he declared had been treated differently to the black perpetrators. This resulted in nursing staff losing control of the ward for a second time when they retreated to the nursing station.’ These allegations of discrimination must not be redacted.
Given that this report is from the largest mental health provider in the country, where two people from the UK’s African Caribbean communities have lost their lives while in the care of this provider at the hands of the Metropolitan Police services, it is particularly important that every member of the committee should be able to read a fully unredacted copy of this report. Considering the serious public safety implications, as well as public confidence concerns in policing and mental health, exemplified by such incidents, it would be helpful for this inquiry to get a full insight into both policing practice on the ground and patient experience at this mental health provider.
 PMH0021 David Mery - written evidence (PDF) [also on this blog at Evidence to the Home Affairs Committee's inquiry into policing and mental health]
The Home Affairs Committee, whose remit 'is to examine the expenditure, administration and policy of the Home Office and its associated public bodies' is running an inquiry into policing and mental health. The deadline for written evidence was a week ago and 34 submissions have been published online on the Parliament's website. The evidence I submitted (PMH0021) is also copied below:
A) Autistic behaviour considered suspicious and subsequent unlawful arrest
B) The River House incidents and its cover-up by the NHS and the MPS
C) The use of section 136 of the Mental Health Act 1983 in London
 Police interview tape; Walworth Police Station; 2005-07-29 03:12:50-03:56:30
 Letter from Chief Superintendent Wayne Chance, Metropolitan Police Service Borough Commander for Southwark dated 2009-09-02: http://gizmonaut.net/blog/uk/2009/09/mps_apologises.html
 Autism: a guide for criminal justice professionals: http://www.autism.org.uk/working-with/criminal-justice/autism-a-guide-for-criminal-justice-professionals.aspx
 Sean Rigg inquest verdict: http://www.gardencourtchambers.co.uk/imageUpload/File/Inquisition-for-Mr-Rigg.pdf
 NHS Trust attempted cover-up over massive police deployment to mental health ward: http://gizmonaut.net/blog/uk/2014/03/SLaM_attempted_cover-up_over_massive_police_deployment.html
 An independent investigation into the circumstances surrounding two separate but related incidents involving Norbury patients on Spring Ward on the night of 1st October 2012: https://www.whatdotheyknow.com/request/164330/response/496004/attach/3/RH%20Report%20Oct12%20unredacted.pdf
 Minutes of the fifty ninth meeting of the board of directors of the South London and Maudsley NHS Foundation trust held on 30th october 2012: http://www.slam.nhs.uk/media/177219/novboard_12.pdf
 An independent investigation into the circumstances surrounding two separate but related incidents involving Norbury patients on Spring Ward on the night of 1st October 2012: https://www.whatdotheyknow.com/request/164330/response/496004/attach/3/RH%20Report%20Oct12%20unredacted.pdf
 Transcript of London Assembly’s Police and Crime Committee on 2013-11-21: https://www.london.gov.uk/moderngov/mgChooseMDocPack.aspx?ID=4993&SID=9700
 More on this confusion in Deployments of armed police officers at London’s mental health units: http://gizmonaut.net/blog/uk/2014/04/mps_at_mhus.html
 Police use of taser statistics, England and Wales, 2012 to 2013: https://www.gov.uk/government/publications/police-use-of-taser-statistics-england-and-wales-2012-to-2013/police-use-of-taser-statistics-england-and-wales-2012-to-2013
 The operation of Section 136 in London, An Action Plan to improve was published in March 2013 by the Mental Health Partnership Board for London. This document does not appear to have been made public; a copy was obtained from David Mellish, Chair of the Mental Health Partnership Board for London.
Barnet, Enfield and Haringey Mental Health NHS Trust: https://www.whatdotheyknow.com/request/mha_s136
Camden and Islington NHS Foundation Trust: https://www.whatdotheyknow.com/request/mha_s136_2
East London NHS Foundation Trust: https://www.whatdotheyknow.com/request/mha_s136_3
South London and Maudsley NHS Foundation Trust: https://www.whatdotheyknow.com/request/mha_s136_4
West London Mental Health NHS Trust: https://www.whatdotheyknow.com/request/mha_s136_5
South West London and St George’s Mental Health NHS Trust: https://www.whatdotheyknow.com/request/mha_s136_6
North East London NHS Foundation Trust: https://www.whatdotheyknow.com/request/mha_s136_7
Oxleas NHS Foundation Trust: https://www.whatdotheyknow.com/request/mha_s136_8
Central and North West London NHS Foundation Trust: https://www.whatdotheyknow.com/request/mha_s136_9
 Transcript of London Assembly’s Police and Crime Committee on 2013-11-21: https://www.london.gov.uk/moderngov/mgChooseMDocPack.aspx?ID=4993&SID=9700
Patients treated in mental health units are vulnerable individuals and deploying police officers to handle them is not the kind of care that patients and their families are expecting. It has on occasions resulted in deaths, often of young black men, such as that of Sean Rigg and Olaseni Lewis. So what is the Metropolitan Police Service's policy for such deployment of their officers?
In their press lines, dated 2014-01-28, the Metropolitan Police Service (MPS) describe their lack of policy about armed police deployments at mental health units:
Q2: Does the Met have a policy on the deployment of armed police to incidents that take place in mental health units?
= The MPS does not have a specific policy in relation to the deployment of firearms officers to mental health units.
Firearms officers are deployed to incidents where firearms or weapons are involved. Decisions to deploy firearms officers will include consideration around the type of premises and the persons concerned.
(Note that firearms officers include not only those in armed response vehicles but also Territorial Support Group (TSG) officers and the forty or so officers per borough trained in the use of Tasers.)
The investigation report into the incident at mental secure unit River House includes mentions of some patients 'making threats' but does not make any mention of either 'firearms' or 'weapons' having been in the possession of the patients. Forty-eight police officers were deployed, including armed response units, and four Tasers were drawn.
Commander Christine Jones, lead on mental health for both the Metropolitan Police Service and the Association of Chief Police Officers (ACPO), expressed a more cautious approach at London Assembly's Police and Crime Committee on 2013-11-21 (pdf) and insisted that all calls for MPS deployment to mental health settings will have to be approved by her team:
Christine Jones (Commander, Metropolitan Police Service): [...] There is also an appetite to take people down to Grays End to show them the Taser training so that we can have the critical third eye from the lens of the community around when it is used and why it is used.
Again, my sense is that on many occasions police have been in that place because there is nothing else and that is the issue we are working through now. Actually, if you need to restrain in a mental health environment, why would that fall to police? If you woke up in hospital after a triple heart bypass and became violent with staff, there is no question that the police would be called. Of course they would not. In a mental health environment, if the right commissioned services do not exist, there has been a reliance on police attending to support staff. I can absolutely understand that, but we need to move on from that and that is the work we are doing. [...]
Christine Jones (Commander, Metropolitan Police Service): [...] I do not think police should be going into mental health institutions to restrain and I have put a stop to it. What I have said is --
Jenny Jones (Deputy Chair): You have stopped the TSG being sent?
Christine Jones (Commander, Metropolitan Police Service): I have stopped police responding to mental health institutions for the purposes of restraint unless there are very, very good reasons why. Claire [Murdoch] and I are busy working through a protocol for London because there are certain areas of London that we get very few calls to and other areas of London that we get lots of calls to. For me, the only time that police should ever go into that health setting, frankly, because you are talking about somebody who is ill, is if there is real danger to life. That is a different issue.
Jenny Jones (Deputy Chair): It is bad for the police as well, of course.
Christine Jones (Commander, Metropolitan Police Service): Of course it is bad for the police, but imagine what it is like for the person. I cannot think of anything more terrifying. We have an escalation process in place at the moment for the Metropolitan Police Service which basically means that if a mental health institution calls on police, it goes into my mental health team to assess the circumstances before we respond. It is as simple as that. We have that level of commitment that we are all on call virtually 24 hours a day to make sure that if we have to respond we have the right people doing it and for the right reason.
Jenny Jones (Deputy Chair): Do you know if this has actually reduced the number of times the police are going to --
Christine Jones (Commander, Metropolitan Police Service): Hugely. Absolutely massively.
The press lines detail some new training for firearm officers and front line officers hopefully resulting in respectful encounters with vulnerable individuals and fewer uses of Tasers:
Q3. Do you recognise the concerns from campaigners about the use of armed police in mental health incidents?
= The MPS takes onboard concerns raised around the use of armed officers to mental health incidents and always places the safety of the public paramount.
Met firearms officers attend special training days where they work with mental health workers and patients to assist them in understanding and responding to people who suffer from mental health issues. We have introduced information sharing protocols to obtain fast time intelligence about any person who may be considered EMD (Emotionally or Mentally Distressed) or suffering behavioural disorders. Training around mental health issues is also included as part of officers on going training as well as forming part of the NPFTC (National Police Firearms Training Curriculum) instruction courses for firearms officers.
In September 2012, the Commissioner requested an independent commission to look at the MPS response to mental health. It was also asked to examine the interface between the MPS, mental health services and other partners.
Since the report by Lord Adebowale was published in May 2013, the MPS has fundamentally looked again at how we work as an organisation, and with partner agencies, to improve services, share information and better understand the needs of people with mental ill health with the aim of delivering a service that can be best adapted to fit individual needs.
The 28 Recommendations within the Independent Commission report on Mental Health and Policing (2013) are being progressed and embedded in the direction of travel for policing, both locally and nationally.
We continue to work locally across London and nationally with partners across the health spectrum and we have also contributed to the forthcoming Department of Health Crisis Care Concordat [(pdf)]. This is where a number of national organisations have committed to work together to support local systems to achieve systematic and continuous improvements for crisis care for people with Mental Health issues.
The MPS are also in the process of rolling out the Community Risk MARAC group (Multi Agency Risk Assessment Conference) and a pilot is currently underway in all NW London Boroughs. This is a local partnership forum, where high risk and developing cases can be discussed and problem solved.
The MPS are also in the process of training all front line officers in the Vulnerability Assessment Framework (VAF). The VAF is a simple investigative approach to assessing vulnerability, in all interactions the police have with the public.
The MPS is committed to delivering a quality of service and care for all those who come into contact with the MPS - especially those who are at their most vulnerable through mental ill health or crisis.
The training of front line officers should have been completed by now and other police staff will be trained by the end of the year:
Christine Jones (Commander, Metropolitan Police Service): Our training plan starts in January for all frontline officers and goes through to March . For the frontline uniformed response, so emergency response officers, all of those who work at borough level, they will receive vulnerability assessment training, as will our core staff. By the end of the year, every single member of the Metropolitan Police Service will have received that training, so that is how we will embed it at every stage. Regardless of what department you work in or at what point you engage with a member of the public, everybody was applied the same approach, so that is point number one. [...]
Absolutely, and that is the point, I do not think we have invested enough in teaching our officers to understand vulnerability. What we have said is, “You need to be trained in this, you need to be trained in this, you need to understand this risk assessment, you need to know ...” No, actually, our officers need to know this, that is the primary issue for us, we need to understand the legal framework in which we operate and then the issue is how we understand the vulnerabilities and diverse needs of our communities and that is my issue. I do not think we have trained our officers effectively in recognising vulnerability. We have done lots and lots around race, we have done lots and lots around professionalising investigation, but actually the human piece around this is how we deal with people on a daily basis, how we recognise their different needs by understanding where they may be vulnerable, and to be perfectly honest the feedback that we have had from the communities in London around satisfaction has regularly told us, “The officer failed to recognise my vulnerability”. We have the evidence there; we are now using it to fundamentally change that frontline training and, as I say, every single officer in London will have had that training by the end of next year and every single encounter we have with a member of the public they must apply that framework.
If you have an interest in policing and mental health it is well worth reading the transcript of this Police and Crime Committee session (pdf) in its entirety. One learns that some improvements have already been implemented. Last year I made a series of Freedom of Information requests to the MPS and London's NHS Trusts to get some data on the use of section 136 of the Mental Health Act and was frustrated by the police keeping their data in paper form at borough level:
Christine Jones (Commander, Metropolitan Police Service): I absolutely reflect that unhappiness. When you have disparate systems, disparate information technology (IT) and technology that does not talk to itself, you are immediately into a difficult arena. Until I took over the lead for mental health back in September last year, we had no way of knowing by pressing a button how many people across London we had encountered with vulnerability leading to mental health issues. We had no way of looking up how many Section 136 interventions we had or Section 135.
We changed that in January this year and in April that rolled out across the Metropolitan Police Service, so we now use the Merlin system to highlight vulnerable adults coming to notice.
[...] Good metrics now under Section 136. We have good metrics now.
Some changes have happened while others are going through the organisation. At the Police and Crime Committee, Commander Christine Jones said she 'took over the lead for mental health back in September last year', i.e., September 2012, a month at most before the deployment of 48 police officers at River House. Police involvement at this incident was covered up by the South London and Maudsley (SLaM) NHS Foundation Trust and the Metropolitan Police Service. I have two complaints currently with the Information Commissioner's Office, one for each of these organisations about how they are still attempting to avoid publication of information related to this incident. To reassure Londoners that policing of vulnerable individuals with mental health issues is improving, the Metropolitan Police Service will have to improve on their transparency as well as their performance.
Home Office statistics show that the use of Tasers keeps increasing, by 27% in 2013 compared to 2012. Police officers in England and Wales equipped with Tasers used them 10,380 times in 2013. More police officers are responsible for this increase. The article Tasers: the 'non-lethal' weapon reckoned to have caused more than 500 deaths, published in November 2013 on The Justice Gap, explains that, '[i]nitially only Authorised Firearm Officers (AFO) were equipped with Tasers, however 'Currently there are 14,700 officer trained to use Tasers [but the] number of AFOs is 6,979.' The Justice Gap has also published a video of a Taser refresher course with the London Metropolitan Police in 'Shocking Britain': the controversial roll-out of the Taser.
The timeline for rollout in the Metropolitan Police Service (MPS) is described in a letter to the London Assembly's Chair of the Police and Crime Committee:
The initial trial of Taser concluded on the 31st March 2004. In July 2007 the Home Secretary approved a year long trial of 10 forces to extend the use to "specially trained units" (STUs). The MPS was one of these forces. Its use was initially restricted to SCO20 (TSG) officers. In February 2012 Management Board supported the extension of Taser to other STUs including those on Boroughs.
In October 2012, when 48 police officers were deployed to River House, an NHS mental health unit (NHS Trust attempted cover-up over massive police deployment to mental health ward), this extension to borough officers hadn't been completed. And the police wanted Tasers to 'managed the situation' involving mental health patients. AC Mark Rowley wrote 'Armed response vehicles responded to this incident as they were the nearest available unit with a Taser capability. You will recall that at this time, only firearms officers and TSG were the only units equipped with Taser.' The MPS confirms that the roll-out of Tasers to trained Territorial Police officers has been completed:
All 32 London boroughs now have a group of officers on their borough who are trained in the use of Taser.
[...] Around forty officers from each borough have been trained in the use of Taser. The initial training is now complete. Taser trained officers are deployed in pairs in two cars on each borough, that's a maximum of 4 officers per 8 hour shift over a 24 hour period.
Even more officers may eventually get a Taser as '[i]n November 2011, Commissioner Hogan-Howe said that all officers should have easy availability of Taser.' (interview with LBC radio as reported in Governance of Taser and other less-lethal weaponry). And as a report published earlier this week by the Independent Police Complaint Commission shows, some of these officers make mistakes with terrible consequences such as firing a Taser on a 63-year old blind man with a white stick when looking for someone in his mid-twenties with a sword.
How Tasers are used is recorded:
|Level of use||Type of use||% uses in 2013 (*)||Definition|
|Highest use||Fired||17%||The taser is fired with a live cartridge installed. When the trigger is pulled, the probes are fired towards the subject with the intention of completing an electrical circuit and delivering an incapacitating effect.|
|Angled Drive Stun||The officer fires the weapon with a live cartridge installed. One or both probes may attach to the subject The officer then holds the taser against the subject's body in a different area to the probe(s), in order to complete the electrical circuit and deliver an incapacitating effect.|
|Drive stun||3%||The taser is held against the subject's body and the trigger is pulled with no probes being fired. Contact with the subject completes the electrical circuit which causes pain but does not deliver an incapacitating effect.|
|Non-discharges||Red dot||51%||The weapon is not fired. Instead, the taser is deliberately aimed and then partially activated so that a laser red dot is placed onto the subject.|
|Arcing||1%||Sparking of the taser without aiming it or firing it.|
|Aimed||5%||Deliberate aiming of the taser at a targeted subject.|
|Lowest use||Drawn||22%||Drawing of taser in circumstances where any person could reasonably perceive the action to be a use of force.|
(*) Percentage for England and Wales that 'excludes Humberside and West Midlands who are unable to provide a full breakdown of taser use'. (Source)
Even though information about Taser use is held, it does not follow that police forces are forthcoming about how Tasers were used at specific incidents. In my Freedom of Information requests to the MPS about the River House incident, no such data was provided. This is subject to an internal review.
Two inter-related incidents involving service users happened on the night of 2012-10-01 at the River House (RH) mental secure unit, part of the Bethlem Royal Hospital run by the South London and Maudsley (SLaM) NHS Foundation Trust. Police were called for both incidents and SLaM has attempted to cover this up. A news story the next day did reveal that Territorial Support Group (TSG) officers were called, but not how many and whether any other specialist units had also been deployed. A few days later a whistle blower and two external third party individuals alerted the Care Quality Commission. When queried about these incidents, SLaM admitted that 'police had been called' without elaborating any further. Data obtained from a campaign of freedom of information (FoI) requests to SLaM, the Metropolitan Police Service (MPS), the Independent Police Complaint Commission (IPCC), the Care Quality Commission (CQC) and Monitor, and an ongoing complaint to the Information Commissioner's Office about the breaches of the Freedom of Information Act in SLaM's responses has revealed the extent of this cover up: 48 police officers were deployed including six officers from armed response units, two from dog units, 21 PC from the TSG and the entire Bromley Borough Night Response team. The TSG, armed and dog units officers are all trained to use Tasers. Further information shows that TSG officers entered the mental health ward and four drew their Tasers. They were called that night to manage a situation involving vulnerable individuals suffering from mental health issues.
SLaM commissioned an independent investigation report. Although dated 2013-05-10, it was eventually published on 2013-08-29 with a large amount of text redacted; simply deleted in non compliance with the Freedom of Information Act (pdf). The minutes of the board of directors announcing this report had been commissioned disappeared from SLaM's website before eventually being republished after contacting SLaM. The authors of the independent investigation report are not named and not known, SLaM wrote on one occasion that '[t]he investigation panel included a consultant lead investigator with a senior nursing background, a Consultant Forensic Psychiatrist and a Forensic Nurse Consultant [... and] that the authors of the investigation report are sufficiently qualified people who are able to conduct such an investigation and were appointed by the Trust Board.' (pdf) and on another that '[t]he investigation is being undertaken by a retired Director of Nursing, a forensic psychiatrist and a senior nurse with experience of security management.' (pdf)
This incident happened two years after Olaseni Lewis died after being restrained by up to 11 policemen at the Bethlem Royal Hospital and only two months to the day after the Sean Rigg inquest verdict, in which SLaM's failings were criticised to have 'more than minimally contributed to the Sean Rigg’s death'. SLaM stated on 2012-11-08 in its first response to my FoI requests that luckily this time 'there were no injuries to patients or staff in this incident'. It reiterated this position to its board of directors: 'there were no reports of any injuries to staff or patients.' However the investigation report states: 'One patient sustained injury to his hand during the second incident. No physical injuries were sustained by staff.' Another discrepancy: at a meeting of Lambeth's Health and Adult Services Scrutiny Sub-Committee, SLaM stated 'The police had been called for support but the incident had been managed well by staff at SLaM and the police did not get involved in the incident', however the investigation report, even though it does not go into details into police involvement, contradicts this statement: 'With the assistance of the Metropolitan Police and the first on-call CAG manager, three of the four patients were, after several hours, placed in supervised confinement (SC) on other wards.'
Following a complaint to the Information Commissioner's Office, on 2014-02-28, SLaM sent in another version of its report with some text previously redacted now included and what remains redacted shown as blacked out text (pdf). As of this writing this less redacted report has still not replaced the first version on SLaM's website.
The following details the shocking information that we have uncovered.
From the investigation report:
This is the report of an Independent investigation commissioned by South London and Maudsley NHS Foundation Trust, following two separate but related patient incidents on the night of 1st October 2012, involving Norbury patients on Spring Ward.
[...] The first incident began at approximately 2200, when one patient, as part of his recurrent delusional state, accused the designated ward-based security nurse on the night shift of stealing designer wear and trainers which he believed his mother had brought to RH for him.
Attempts to deescalate this incident were unsuccessful. Although a decision was taken to offer the patient prn medication, a second patient destabilised the intervention and two other patients subsequently became involved. Staff considered the situation to be unsafe and retreated to the nursing station.
Assistance from the Metropolitan Police was first requested at 2244 and the first police officer from Bromley Police Station arrived promptly at 2247.
The police contend that on arrival they were unable to access key information about the patients involved in the first disturbance which frustrated their ability to risk assess the situation.
[...] With the assistance of the Metropolitan Police and the first on-call CAG manager, three of the four patients were, after several hours, placed in supervised confinement (SC) on other wards. The clinical environment was restored at approximately 0230.
In the second incident which occurred at approximately 0250, one patient challenged staff with regard to decisions which had been taken about the management of the four patients involved in the first incident. He accused them of discrimination, believing that there had been a racist motive and that staff had assisted the police to pursue this line of action. He threatened to kill staff and one of the white perpetrators, who he declared had been treated differently to the black perpetrators. This resulted in nursing staff losing control of the ward for a second time when they retreated to the nursing station.
This [second] incident also required intervention from on-call managers and the Metropolitan Police. The clinical environment was finally restored at 0500.
SLaM suggests only local police showed up
The day following the incident, the Bromley News Shopper ran a story, Bethlem Hospital secure unit incident attended by police and firefighters:
Officers from Bromley police and the territorial support group dealt with the situation and left the scene at around 2.50am.
And three fire engines were sent to the scene at about 12.30am after receiving reports of a fire alarm going off but there was no fire.
There were no arrests or reports of any injuries to staff or patients.
A whisteblower contacted the Care Quality Commission (CQC) by 2012-10-11 with concerns relating 'to safety of patients and staff and level of incidents.' The next day, the CQC MHA [Mental Health Act] Operations Manager wrote to the CQC Compliance Inspector:
[...] 2. Patients safety incident on Riverside Unit (involving -----)
This is a very serious matter, clearly the ward team lost control of the care of their patients and the situation may well have been much more serious than it has been. I noted the trust have provide a 'fact finding' report and commissioned an independent investigation.
3. Whistle blowing information received
This information appears authoritative and provides background information which would have [sic]
I felt the priorities are as follows:
a) Immediate. From the documentation sent through, unless there is other information I have not seen I am concerned that the provider does not appear to have demonstrated that they have taken robust action to make the ward environment safer in the light of the incident. This they could do quickly by, for example, increasing staff numbers, decreasing patient numbers, closing to new admissions for a temporary period. Further, issues of staff training, availability and skill mix all seems to be pertinent issues here. These are not ones that should need an independent clinical governance report to help them address. Should they not be able to identify and address issues immediately without recourse to an independent investigation then this further erodes confidence in their management capabilities. [...]
A 'third party individual' was concerned enough to get in touch with Care Quality Commission (CQC) on 2012-10-18. The CQC summarised the received email:
The concerns can be summarised as follows:
- Complainant wished to inform CQC of a violent incident that occurred on the SLAM secure forensic wards on Monday 1 October 2012 and request CQC investigate it
- Overall concerns raised for the safety of detained patients, in particular those from ethnic minorities - especially in light of the Sean Rigg Case in 2010.
- Overuse of restraint and medication
- Culture of intimidation
- Allegations that the trust was covering up details of the incident on 1 Oct, especially in relation to police involvement.
- Over representation of BME people being detained by the Trust
The complainant also made a request for information relating to the incident and its aftermath including:
• Information relating to the police becoming involved, numbers, equipment used, action taken by police against patients
• Numbers of patients involved
• Any injuries sustained by patients
• Details of any restraint or increase in medication of patient following incident
• Timing of incident/resolution
• Reasons for incident
Another concerned third-party individual wrote two letters on 2012-10-22. One addressed to the Care Quality Commission and another to alert the chair of Lambeth's Health and Adult Services Scrutiny Committee, copying the Lambeth Council Cabinet Member for Health and Wellbeing, the Chief Executive of the Care Quality Commission, a Special Correspondent at the BBC and the Director of Black Mental Health UK:
[...] This letter is to request that the CQC conduct an independent investigation into the matter and SLAM's treatment of its patients, particularly those from ethnic minority communities as a matter of urgency.
The recent high profile fatalities of black men in the care of SLAM make this latest incident of particular concern.
The Sean Rigg inquest verdict concluded that SLAM's negligence had more than minimally contributed to his death. Rigg died in 2008 and SLAM made public statements that improvements have been made in the treatment (particularly of black patients detained in their care).
However, in 2010, -------------- [the name of Olaseni Lewis is redacted in the copy of this letter disclosed by the CQC] died after he was restrained by 14 police officers for 45 minutes while on a secure ward run by SLAM.
After police release ---- [Lewis] and he was lying in a semi conscious state on the floor of a seclusion room, SLAM staff then injected him with antipsychotic medication. The inquest into the death of --------- [Seni Lewis] will being in March 2013 [this inquest has since been delayed].
I think it is important for the CQC to be aware of the recent history of this trust as it is in light of this that I am writing to you as the health regulator about the riot that occurred on wards run by SLAM on the evening of Monday 1 October 2012.
I have been made aware that the over use of force and high doses of antipsychotics and tranquillisers dominates the way patients are treated in secure wards run by this Trust.
The oppressive culture of this health provider may have been a factor behind the riot at the Bethlam [sic] which is run by SLAM on Monday 1 October.
This letter is also to request that you contact the chief executive of SLAM regarding the issues that have been raised in this letter and also for the CQC to conduct an independent investigation into this incident.
The particular concerns about the incident, which I would like the CQC to investigate include: establishing level of police involvement. It would be helpful to establish how many patients were restrained or subject to force by the police during this incident. I would also like the CQC to find out if Tasers, CS spray, Alsatian attack dogs, batons, hand cuffs or riot gear was used during this incident and also the levels and number of psychical injuries sustained by patients.
I look forward to hearing from you as to what action will be taken in response to this complaint; I would like to know how this information will be made available to the general public. [...]
The investigation report was not conducted by the CQC but commissioned by SLaM, and the CQC has no issue with the amount redacted in the heavily redacted version first published: 'The report published by the Trust is intended to demonstrate accountability for issues which arose at the Trust and to show how the Trust intends to prevent similar occurrences in the future. CQC does not consider that the addition of the redacted passages in the Report would further demonstrate accountability, and would instead be more likely to cause significant safety concerns for staff working in River House (and in fact officers from other agencies such as the Police, Ambulance Service and Fire Brigade).'
At the meeting of the Health and Adult Services Scrutiny Sub-Committee, on 2012-10-23, SLaM was asked about this incident, and its response carefully avoids any details even those already known such as the attendance of TSG officers and paints a rosy picture:
In response to queries from Members, representatives from SLaM made the following comments:
[...] A serious incident had occurred the previous week at the Bethlem involving two patients at SLaM taking other patients and staff hostage. The police had been called for support but the incident had been managed well by staff at SLaM and the police did not get involved in the incident. This demonstrated that improvements had already been made to the way in which the Police and SLaM were working together and the team which was called in to deal with such situations were adequately trained.
[...] As follow up actions he proposed that: [...]
· A note of the meeting be sent to Monitor
· That the principles of openness and transparency should be endorsed by health trusts. It is healthy for the health overview and scrutiny committee to be informed of instances such as occurred on 1 October 2012 and all should work towards a protocol on sharing information.
The board of directors of the South London and Maudsley NHS Foundation Trust was notified of the incidents at the 2012-11-27 board meeting:
Gus Heafield reported that there was an incident involving patients at River House at Bethlem Royal Hospital on the evening of 1st October 2012. Staff responded promptly and professionally and called the police who attended the scene with fire crews. The incident was contained within the unit and there were no reports of any injuries to staff or patients. An external investigation will be carried out and it was noted that the three members of the independent panel had been appointed and terms of reference for the review had been agreed. The review was due to be completed in January 2013. The Care Quality Commission had been notified of the incident and has been kept informed about the independent review.
Again, the investigation report as it was first published on 2013-05-10 did not mention the presence of Territorial Support Group (TSG) officers that were known to be on the scene from the earlier news story or any more details about the amount of police involvement:
This [first incident] necessitated intervention from the RH Rapid Response team, The Bethlem Royal Hospital (BRH) Emergency Team, various on-call managers from the Behavioural and Developmental Psychiatry (BDP) Clinical Academic Group (CAG), an On-Call Executive Director, the Metropolitan Police, the London Ambulance Service, and the presence of the London Fire Brigade.
Fifteen months later, we learn that 48 police officers were deployed including officers from armed and dog units
In responses to Freedom of Information requests, the Metropolitan Police Service (MPS) after describing that the 'disturbance at the River House facility, was treated as a critical incident by the MPS and accordingly involved many different police units' eventually gave an account on 2013-12-31, of the scale of its involvement:
The number of officers initially deployed were:
1 Police Sergeant
10 Police Constables from the response team at Bromley.
The Inspector declared the incident "otherwise so dangerous" and requested Commissioners Reserve.
As a result further officers were deployed which were:
21 Police Constables from the Territorial Support Group. (TSG)
6 Police Officers in two vehicles from the Armed Response Unit (ARV) - These were stood down upon the arrival of the TSG
2 Police Officers from the Dog Unit (with two dogs) - These were stood down upon the arrival of the TSG
1 Detective Sergeant,
1 Detective Constable from Bromley
In the version of the investigation report SLaM published on 2014-02-28, SLaM unredacted the following:
This necessitated intervention from [...] three divisions of the Metropolitan Police
[...] In the course of approximately three and a half hours, somewhere in the region of forty police officers were on-site, ______________________________________________ the Territorial Support Group (TSS) [sic] – Commissioner’s reserve, three police dog units and Trojan (specially trained armed officers).
[...] The Lock Down policy stipulates that for a major incident the Bronze, Silver and Gold command structure should be established.
As SLaM didn't follow proper procedures for redacting text, we also found out that SLaM attempted to cover up that the entire Bromley Borough police night response team was deployed to River House and that it failed to put in place a proper command structure:
In the course of approximately three and a half hours, somewhere in the region of forty police officers were on-site, comprising the entire Bromley Borough Night Response team, the Territorial Support Group (TSS) [sic] – Commissioner’s reserve, three police dog units and Trojan (specially trained armed officers).
[...] The Lock Down policy stipulates that for a major incident the Bronze, Silver and Gold command structure should be established.
The police adopted this modus operandus, but despite the fact that several managers became involved throughout the night, four of whom came on-site at various times, there is no evidence that the Bronze, Silver or Gold command roles were assigned to Trust staff to work with the police accordingly.
Armed police officers, dog units and riot police officers have no place on a mental health ward. Having a situation deteriorates to the point that SLaM and the MPS decided it needed such a high police response brings serious concerns as to the safety of the vulnerable service users being treated.
Many questions remain unanswered
We know that the Metropolitan Police Service classified these incidents as critical and that they established a Bronze, Silver and Gold command structure. However we do not (yet) know from which units officers forming this command structure came from, and we do not know if any weapon, whether guns, Tasers, batons or CS sprays were drawn and / or used, or whether any dog was released. London Assembly member Baroness Jenny Jones has written to Sir Bernard Hogan Howe, Metropolitan Police Service Commissioner, Sarah Green, ICC Deputy Chair and Norman Lamb, Minister of State for Care Support to raise her concerns and ask for this information.
The only records the police have so far managed to find or 'locate' are exempted from disclosure. It is also likely they are reading the request too literally as they claim not to have any 'final report' for the incident but it is most likely they would have a report of some sort or similar document for a critical incident involving so many officers from several units and a command structure:
To assess who or may have relevant information for this request at least 12 (Twelve) separate CAD messages, the MPS electronic message system, were created and run for the incident mentioned. [Source]
Despite our searches there is no information held in regards to the final report [completed for the incident]. [Source]
The records held include ten CAD reports [Computer-Aided Dispatch] and one CRIMINT report [Criminal Intelligence database]. The CADs relate to the 999 call and subsequent dispatch of officers, the CRIMINT is an intelligence report.
I have been informed that on Incident Management Log was created however despite searches on borough and with the senior investigating officer I have not been able to locate this document.
Furthermore one document refers to a meeting in which this matter was to be discussed, again no further information could be found in respect of this meeting which may or may not have occurred. [Source]
The IPCC does not have any information at all about these incidents:
I am writing to advise you that, following a search of our paper and electronic records, I have established that the information you requested is not held by the IPCC. This is because the IPCC was not involved in this incident.
Section 3 of the investigation report is a list of recommendations, some requiring immediate action and the latest one due by March 2014. Apart from the vague description of some immediate actions taken to make the ward safer listed in an email dated 2012-10-15 between the CQC and SLaM (names are redacted), we do not know whether any of the recommended actions have been implemented; we also do not know whether any restraint were used on patients and the effect this situation had on both patients and staff:
- the patient's [sic] involved in the incident were placed under enhanced levels of care: -- [redacted] transferred to ------- Clinic, -- transferred to HMP -------, -- transferred to HMP -------, -- transferred to ------- ward and -- remains on ------- Ward.
- making the immediate environment safe
- undertaking repair where necessary
- security systems were checked
- the perimeter fence was examined (no breaches had occurred and the fence was undamaged)
- all patients on the ward were subject to updated mental state examinations and risks were reviewed
- debriefing sessions were held with the staff who were also reassured that an independent investigation would be undertaken
Some of the findings of the investigation report show a continuing need to improves safety: '[t]he lack of awareness of the risks outlined above and the ease with which these were quickly identified by the Independent team, suggests a less than optimal grip on environmental security in which safe clinical practice takes place' and '[s]ystems and safety culture are the root cause of the majority of incidents and no less so in relation to what took place on the night in question.'
Between 2012-01-01 and 2012-10-19, 196 violent incidents at River House were reported to the National Patient Safety Agency. Of these 101 were within the Bromley Local Authority and 95 in Lambeth.
|Assault by a patient||77|
|Harassment by a patient||4|
|Sexual Assault by a patient||2|
|Sexual Assault by a staff member||1|
|Assault by a staff member||1|
|Assault by other (e.g. a visitor)||1|
It is not known whether the police was called to any of the other violent incidents reported. As safety of patients and staff is paramount, SLaM must become more transparent into the way it operates.
The day following publication of this article, SLaM has accepted that its use of Freedom of Information exemptions was unwarranted:
As you know, the Trust has previously withheld some aspects of the Report from disclosure by applying the exemptions in sections 38 (health and safety) and 40 (personal data) of the Freedom of Information Act (2000).
Following your complaint, the Information Commissioner’s Office has undertaken an independent assessment. The Trust has now resolved to withdraw its use of the exemptions in sections 38 and 40 of the Freedom of Information Act (2000) to the Report and to disclose it in an un-redacted form.
The version of the investigation report just sent in with the blacked out text now visible is available here (pdf). To identify more readily the new information, I had recreated the document highlighting the differences but had not released it until now in case the Information Commissioner's Office (ICO) ruled some exemptions were justified; you can check it here (pdf).
There remains one unaddressed issue in my complaint to the ICO, the investigation report mentions, on page 10, 'section 17 of this Independent report' however there are only three sections in the published report. Also mentioned, on page 2, is that the 'report refers to ten patients, whom for the purposes of confidentiality have been anonymised (referred to as patients A to J)', however only patients A to B are referred to. These are either typos or there are further missing sections.
London Assembly member Baroness Jenny Jones has kindly shared the letter (pdf) she has received last week from Assistant Commissioner Mark Rowley. It clarifies that only TSG officers, armed with Tasers, entered the mental health ward (25 TSG officers had been deployed at River House) and that out of those that entered the ward, four drew their Tasers:
[...] The Commissioner’s reserve of TSG [Territorial Support Group] was deployed to resolve this incident and when they arrived they effectively took over from the ARV's [Armed Response Vehicle units]. I would stress that they [sic] ARV's never left the rendezvous point. As you may be aware the Commissioners reserve operate as a single unit of 1 Inspector, 3 Sergeants and 21 PCs. This of course would contribute to the seemingly large number of officers on scene at the incident. However, only officers from the TSG entered the ward and although 4 officers had their Taser drawn, through effective use verbal commands they safely resolved the situation without any further use of force. I can also confirm that the Dog support units did not deploy on to the ward.
[...] I am sorry that you have heard that this incident has damaged the confidence of black Londoners in relation to policing and mental health. This scale of incident is quite rare, in fact the MPS has reduced the number of calls that it attends at health based places of safety by 70%, but I remain concerned that police officers are being asked to carry out restraint in mental health facilities. To try to resolve this, protocols between health service managers and police Duty Officers are currently being developed. [...] Unfortunately there is no current time frame for this work to be completed.
This does not state whether TSG officers did restrain any patient that night, and if so how many (the investigation report describes that police assisted in placing three patients in supervised confinement). Also AC Mark Rowley figure of 70% reduction of police calls is meaningless as no period is given, nor a basis or a target for this reduction (and the definition of 'health based places of safety' is open to interpretation).
SLaM has published the list of actions it has taken as a response to the recommendations of section 3 of the investigation report in this pdf.
Relevant Freedom of Information (FoI) requests and other sources (note that the date for FoI requests is the date when the request was sent):
First published on 2014-03-20; last updated on 2014-05-05 (added mention of SLaM unredacting the blacked out text in the investigation report, the letter of AC Mark Rowley to Jenny Jones, the publication of the response to the recommendations and minor other corrections).
[This is an extended version of a guest post that was published by The Restart Project.]
About a year ago, my sister in law got a free iPhone 5 from her network. She had no use for it, so she gave it to me. Recently I noticed a couple of problems: the top power switch is becoming harder to operate, and more annoyingly the pictures taken with the phone show spots and dust marks.
I didn't have any paperwork for the phone, but believed it was still under warranty as the first photo I took with the phone is dated February 28th last year. Even counting a week in the post, my sister in law was likely to have gotten it less than a year ago, so I booked an appointment with an Apple Genius at the Covent Garden store.
The famed Genius Bar is gone, it has been replaced with many smallish high rectangular table where everyone wait on stools for Geniuses to come in your personal space. As my personal Genius equipped with an iPad, explained, it is now '360 degrees'. It makes for a very noisy environment and he could hardly hear what I was saying.
After ensuring my phone was on one of the shop's two WiFi networks and that 'Find my iPhone' was deactivated, my Genius ran some remote diagnostics and declared that the phone was five days out of warranty. He explained that there was no grace period. He was happy to 'fix' as long as I didn't mind contributing a flat fee of £209!
He explained that the spots were inside the lens of the camera, that they don't have camera modules anymore so they just replace the iPhone. The difficulty with the power switch was caused by some rubber disintegrating. He offered to get rid of the dust on the lens for free and disappeared with the phone for five minutes. When he came back, there was a bit more dust! The Genius stated that he found there was a lot of residue in the phone and that could be part of the problem.
Both the power switch issue (documented here and here) and the camera one (documented here) are widespread among iPhone 5 owners and considered by all, but Apple, to be manufacturing defects that tend to manifest themselves after about a year. There's even a small petition about the power switch issue.
As I was unwilling to part with this much cash for fixing manufacturing defects, and the Genius suggested I check with my sister in law for any paperwork showing the phone was still in warranty. I had a frustrating discussion with him, asking why Apple won't fix what are widely known issues that are not caused by the user. He explained that he has no discretion.
No paperwork could be found, and nine days later I was back in the Apple Store, this time joined by Ugo, co-founder of The Restart Project. We went through a similar process, but also showed that older photographs taken well within the warranty period already exhibited spots, and some just before the warranty expiration also showed dust marks.
We then mentioned to him that according to Apple discussion forums, Apple has in other occasions accepted such evidence to provide a replacement.
Our clear awareness of the issue at stake and of online evidence in support of our claim, as well as the polite persistence which we used, convinced the Genius that he could have a chat with his supervisor, who approved a replacement.
The 'Problem Description/Diagnosis' in the 'Work Authorisation & Service Confirmation' is as follows:
Issue: Spots in camera
Steps to Reproduce: Issue has been observed and verified on the bar
Proposed Resolution: Replacement in warranty as customer has proof of issues existing from time of purchase.
Cosmetic Condition: Light wear and tear to enclosure
The Genius brought a replacement iPhone 5 and explained that when they discontinue a model, they manufacture some more parts for warranty purposes. The extra 'part' that had been manufactured was a whole phone. (Replacement parts come with a 90 days warranty.)
This replacement phone had been built between 18 and 24 November 2013 (according to CoconutID) and was running iOS v6.1.4. Apple both discontinued the iPhone 5 and released iOS v7.0 in September 2013, months before this replacement had been manufactured.
When asked what would happen to the phone with the damaged camera module and power switch, the Genius volunteered it would be 'destroyed'. A replacement rear camera module is available online for a tenner and the power button cable for two, but not from Apple.
The true cost of mobile phones is high as Gaia Foundation's Wake up call shows. Manufacturers must take responsibility for manufacturing defects for the useable life of their products. Externalising such costs on the consumer creates a perverse incentive for planned obsolescence.
Bootnote: Read an earlier post on becoming a restarter.