Thu, 20 Mar 2014

NHS Trust attempted cover-up over massive police deployment to mental health ward

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)

2012 annual march against deaths in custody

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.

The incidents

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 Inspector
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:

2 Inspectors
3 Sergeants
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:

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.

Category Number
Assault by a patient 77
Challenging Behaviour 50
Aggression 42
Inappropriate Behaviour 18
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
Total 196

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.

Update 2014-03-21

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.

Update 2014-03-24

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).

Update 2014-05-02

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).

websiteblogblog archivenews feedfeedback