Dealing with aggressive and violent people is difficult enough – and even more fraught in healthcare settings such as accident and emergency (A&E).
Healthcare staff want to do their job, in spite of an agitated, confused or resisting patient, spitting or swearing. In a word, there are dangers to staff and other patients, but also a danger that the aggressive person doesn’t get the care he needs. Take the case of Christopher Alder. In April 1998, the 37-year-old died in police custody after he was assaulted outside a nightclub in Hull and had head injuries. Ambulance crew treated him at the scene; next by hospital staff in A&E at Hull Royal Infirmary. A&E staff later described his behaviour as aggressive, and difficult to manage and calm. He was discharged from hospital – before a doctor’s diagnosis – into the custody of the police for a breach of the peace. The same ambulance crew treated him at a Hull police station. An inquest into the death in August 2000 returned a verdict of unlawful killing.
Tensions
So? The inspection body the Healthcare Commission reported in 2005 said: “This case illustrates the tensions for healthcare staff in managing patients who display aggressive or violent behaviour towards them, whilst ensuring that they receive appropriate care and treatment.” After the report, the Healthcare Commission called for a national protocol between the police and the NHS so hospital staff can deal with unco-operative or aggressive patients, while ensuring they receive treatment. Anna Walker, Chief Executive of the commission, said: “Christopher Alder’s death was a tragedy. There are important lessons to be learned both for the NHS and the police We know that difficult situations occur most nights of the week in A&E departments across the country. Dealing with patients in A&E can clearly be challenging for staff. Sometimes the police may need to be involved. But lessons must be learnt from this case. Protocols are needed to clarify the role of the police and to ensure patients are not discharged into their custody without their healthcare requirements being fully met.”
Agreement expected
A NHS Security Management Service spokesman said: “An agreement between the NHS and the Association of Chief Police Officers to clearly define the roles and responsibilities of the police in the NHS is expected to be signed shortly. This national agreement will be implemented at a local level by the network of local security management specialists in the NHS. Part of this agreement will be that the NHS and the police need to effectively tackle aggressive behaviour by patients whilst ensuring that they receive the care they need. The NHS Security Management Service is constantly revising NHS procedures for keeping patients and staff safe and secure. We will look at the Healthcare Commission’s recommendations and advise the NHS accordingly. Working with the police, the new Local Security Management Specialists investigate security breaches and implement new systems to help protect NHS staff and patients. During a five-week intensive training programme at the NHS SMS Training Centres they receive professional training in areas such as investigative interviewing and a background in law.”
Police flaws
The commission’s report did point to what it called more serious flaws by the custody police, who thought Mr Alder was faking unconsciousness. From interviews and CCTVfootage the report went into detail about police and NHS treatment of Mr Alder on the night of his death, which included a security guard who developed a rapport with the man while he was in an A&E cubicle. The report added: “Security staff were employed by the trust at the time of Christopher Alder ’s death but their role was to patrol and protect the building.They would, unofficially, provide support to the staff in A&E but it was not their responsibility to manage violent and aggressive patients.” Police happened to be in A&E, and according to the report spoke of using CS spray against Mr Alder’s abusive and threatening behaviour. As the report put it: “Although the police were often present in the A&E department, the absence of a joint working protocol resulted in staff being unclear about their role and function and what powers they were able to exercise. The fact that the police threatened to use CS spray [indoors in A&E] demonstrates that they too, were unclear about their role and the extent of their powers in the A&E department.”
No protocols
As the report noted, the hospital security staff in 1998 had training on the job apart from mandatory training in fire and moving and handling objects and people to reduce risk of injury. “All security staff now receive a range of training including conflict management, communication in a stressful environment (run by Humberside police), and health and safety …” Since April 2004, the trust has funded a (part time) police liaison officer, the report noted. However, there are still no protocols in place about the role and powers of the police in A&E: “Police officers in 1998, and now, work under the direction of the nursing and medical staff. The only formal agreement in place relates to time taken to respond to requests. Hull Royal Infirmary has been made an ‘eck ’. This denotes the highest level of priority for attendance.”
Blurred responsibilities
Besides flawed decisions by some individuals, and failures to share information, the report found blurred responsibilities between police and NHS. It called for the NHS and police to work out how to manage violent people who however need treatment; and for training, in for instance use of restraint. And it recommended more documentation.
Dilemmas
There are dilemmas here. As the report admitted, ‘NHS organisations need to ensure that their policy for zero tolerance of violence and aggression towards staff is balanced between protecting the healthcare staff and protecting the rights of patients’. Take the Hull RI, these days part of Hull and East Yorkshire Hospitals NHS Trust. Last year it reported that the incidence of security watches for problem patients was increasing, costing the trust tens of thousands of pounds extra on security guards for problem patients. The Trust stressed that violent and abusive patients may be refused treatment if they are perceived to be a real threat to others.
‘Anti-social not acceptable’
Andy Thompson, the Trust’s Local Security Management Specialist, said in August 2005: “We have spent over £40,000 since January 1 just to provide some of our wards with an extra security presence. Violent and aggressive patients can be refused treatment in some circumstances but sometimes we are not aware of their behaviour until they are already on a ward and then we need to employ specially trained security guards to monitor them. This kind of anti-social behaviour is not acceptable. People who are in hospital for treatment are some of the most vulnerable people in society and the last thing they need is to be threatened or feel threatened by a fellow patient. They have a right to feel safe and secure in hospital and relatives should not have to cope with additional worries about the welfare of their loved ones. Our staff should be allowed to care for their patients without the risk of harm, additional pressure and disruption theses people cause. The Trust does all it can to protect patients but individuals have a responsibility to behave accordingly and respect those around them. Being in hospital does not excuse anti-social behaviour and I would like to stress that anyone who is identified as a threat to other patients or staff is likely to be prosecuted. Even if we do not always take prosecutions down the criminal route we are able to prosecute using civil laws. We will not tolerate this kind of behaviour.” And as another sign of the security situation in A&E, the report added that police are still called to manage patients who for example are drunk and aggressive, or when fights break out between victims and assailants, if they meet in A&E. “The police also bring prisoners who are in custody to A&E for treatment. The police are called to A&E on average three to four times a week in Hull and East Yorkshire NHS Trust. At times,there have been up to 12 police officers in A&E.” p
Fewer face violence
While last issue we featured a survey by the Royal College of Nursing (RCN) that claimed attacks on nurses are increasing, the Healthcare Commission’s recent annual NHS staff survey suggests fewer NHS workers face violence and abuse from patients and their relatives.
The commission praised NHS trusts on what the inspectors called the first significant sign of a trend towards fewer staff facing physical attacks, bullying and harassment from patients or their relatives. Out of 209,000 respondents, 28 per cent said they had experienced either violence or abuse in the previous 12 months, compared with 31 per cent in 2004 and 32 per cent in 2003. But the Commission said it was too early to say whether the trend would carry on and urged NHS trusts to continue their efforts to tackle the problem. The survey highlighted low numbers of staff reporting incidents of violence and abuse. These account for only half of those experiencing harassment, bullying or abuse from any source, and only 67 per cent of those experiencing a physical attack. Only half of those questioned agreed that their employer would take effective action if staff were physically attacked. Only one in four reported that they had had training in preventing and handling aggression from others in the last 12 months. Commenting, Jim Gee, Chief Executive of the NHS Security Management Service (NHS SMS), said: “We are very pleased with the results from the commission survey. The survey highlights a 2pc reduction in staff saying they have experienced violence by patients or relatives over the past year and a 3pc reduction from 15pc to 12pc since the SMS took responsibility for tackling the issue in 2003. This shows our approach is starting to take effect. However, we are not complacent, and realise there is much more to be done to properly protect staff. Training plans from health bodies in England show that by the end of March 2006, one in three of all frontline NHS staff will have been trained in conflict resolution. By March 2008, all 750,000 will have been trained. We are also determined to create a pro-security culture within the health service, where more staff report incidents, so tough action can be taken. NHS Security Management Service research demonstrates that this culture is beginning to develop. Instead of viewing it as part of the job, NHS staff are now more confident in reporting incidents of violence. The latest NHS staff survey by the NHS SMS showed that only 8pc of staff said they left incidents of violence unreported because they felt action would not be taken. This compares to 29pc in the previous year. We are determined to protect NHS staff, so they can better protect the public’s health.”
