Last June, Police Constable Matt Mildinhall of the British Transport Police boarded a busy train headed north from his station in East Anglia. The Met Police had called his team to alert them that a woman could be contemplating suicide and sent over her details. PC Mildinhall's task was to stop her.
“Hi, I'm Matt,” he introduced himself to the middle-aged woman, when he spotted her on the train. “I'd really like to speak with you.”
Last year, the British Transport Police (BTP) estimates, 326 people took their lives on Britain's railways, nearly one each day.
To combat the rising number of suicides, the BTP launched a new programme that embeds mental-health care into their police work and repositions the force as a shepherd into the care system. The first year of comprehensive results have now been collated and the data is striking. Of the 1,156 passengers the BTP brought into the programme in 2014, only 10 went on to take their lives. Under the BTP's new strategy, known as the Suicide Prevention Plan programme, officers are trained to identify and approach potentially suicidal passengers and to work with mental-health nurses to record a roadmap for the passengers' health care. The goal is to guide distressed passengers away from the tracks and towards the services that can help them recover. Emily (not her real name) is the passenger PC Mildinhall approached in June. “I was going through a crisis,” she says. “I wanted to die.”
Emily was diagnosed with bipolar disorder more than 30 years ago, and in recent months, she struggled with suicidal thoughts – until PC Mildinhall reached out.
“Officers can sometimes make you feel like, 'Oh god, another bloody mad person,' but they didn't. They really didn't make me feel like they had better things to do.”
PC Mildinhall offered to treat Emily to a coffee. While they waited for an ambulance back at the railway station, he phoned the BTP control room and Emily's crisis care coordinator, who had initially flagged concerns to the police. The coordinator had spoken with Emily earlier in the morning, and something had seemed off. Emily usually buzzes with stories, but on this day, she was cold and steely – a sign of her suicidal thoughts.
After Emily had finished her coffee, PC Mildinhall himself had one more task for the day. He accompanied her to a nearby mental-health hospital and waited until she was seen by a doctor. For most police forces in Britain, mental-health interventions usually end there. Officers use their power through the Mental Health Act to lead civilians to a safe place in the health system or to police holding cells, where the individuals will then wait for a mental-health assessment.
But for the BTP, this is now where the bulk of their work begins. Nine mental-health nurses have joined the staff under the new programme, and their only job is to oversee care for suicidal passengers on the transport system. Once a suicidal incident occurs in the field, officers or control room staffers contact the nurses.
Equipped with NHS computers, the nurses can access the individual's health care files and alert the listed health team to coordinate follow-up care. Most importantly, the nurses and officers work together to start a “suicide prevention plan”, a file recorded on BTP servers that includes both information on the patient's risks and also a tailored roadmap to recovery.This new kind of police file allows for a two-pronged approach to suicide prevention for passengers at the greatest risk. From BTP offices, nurses can log the passenger's key contacts, follow up with care workers and relatives to monitor progress, and assess the risk of future suicide attempts. In the field, officers will immediately see this file in the case of a second incident. They can review the patient's full mental-health profile and activate the suicide prevention plan.Though Emily wasn't aware of the intricacies of these communications, she knows that she benefited from them. When she returned to London and saw her doctor, psychiatrist and other care workers, they all knew about the incident. Emily say that, in a way, she was relieved. It meant that she couldn't choose to deny the episode. She also didn't need to map out her own recovery: her health team had already set in motion a coordinated plan to manage the crisis.
Mark Smith, head of suicide prevention and mental health at the BTP, launched the Suicide Prevention Plan programme in 2013. The idea germinated years before, when he was detective chief superintendent for the force. He watched as his officers were deployed to suicidal incidents nearly every day, but the death rates continued to rise. As well as the tragic loss of a life, “each event traumatises the driver of the train, the passengers that are on it, and the people that then have to respond to it,” he says. “You've also then got the enormous impact on the bereaved and the communities involved.” So, he turned his attention to prevention.
In 2010, Smith launched the BTP's first iteration of a suicide reduction programme, known as PIER plans, which directed BTP officers to create the suicide prevention plans themselves. Officers also began to attend training courses through Samaritans, the suicide prevention charity, on how to approach passengers at risk of suicide and to lead them to a place of safety. The BTP launched its own in-house training courses, too.
PC Mildinhall went through both training programmes, and he says that they have helped him communicate with potentially suicidal passengers. “It also makes you think a couple of steps ahead,” he explains. “If the person has had an intervention in the past, why didn't it work? Is there something we're missing, something going on in their lives that we don't know about yet?” When he learns the answers to questions such as these, he can log them.
But as the training took off, the BTP quickly ran into a major obstacle. When officers tried to access information on passengers' health risks and tailored plans for ongoing care, they struggled to convince health workers to respond to their requests for patient information. Their calls to doctors and social workers were often met with suspicion.
The Data Protection Act, however, does permit the transfer of some information between health organisations and police, particularly when the agencies are protecting the “vital interests of the data subject”. Health workers, though, were unaccustomed to the requests, and they were cautious of contravening the law. Officers often had little choice but to submit official requests through faxes and secure emails – red tape that stymied their efforts towards a live response to an unfolding crisis. So Smith, with his deputy chief constable at the time and the chair of the British Transport Police Authority, brought the NHS to the table, and the new Suicide Prevention Plan programme was born. NHS London provided funding for nurses to join the BTP's team in 2013, and the programme was relaunched. Each day, around three nurses filed into BTP office suites in London to advise officers in the case of potential suicide and to communicate directly with relevant health workers in each intervention.
It was this close coordination with health workers that transformed the BTP's vision into a viable process. “Suddenly, when we had the benefit of working alongside health workers, they could have those conversations on a one-to-one basis with their colleagues,” Smith says. “And they won't tell us necessarily all the information about a patient, they'll only tell us what's necessary to help us with our judgments about risk.”
Risk, in this case, can come in many forms. Some passengers may have a history of storing sharp objects in their belongings, for example. Others may have aural hallucinations, in which case police and ambulances could mute their sirens. For Emily, care for her dog was a key concern. She once refused a hospital bed in a moment of crisis because she didn't want to leave her dog home alone. PC Mildinhall and his team, on the other hand, asked her for the number of a friend who could watch her pet before she was admitted to the hospital. A note on the need for a dog-sitter in a BTP suicide prevention file is exactly the kind of detail that could help patients like Emily feel more comfortable going into care.
Since the relaunch in 2013, suicide prevention under this programme has markedly improved. In BTP's 2012 pilot without nurses, five of 137 people placed on suicide prevention plans went on to take their own lives, or 3.6 per cent. Once the BTP incorporated nurses into the team, that figure dropped to less than one per cent. Now, mental-health nurses are staffed to cover cases on tracks across all of England and Wales.
Although the programme is focused on reducing railway suicides, its reach extends beyond the country's tracks. Once a suicide prevention plan is composed, the BTP creates a record on the Police National Computer, which hosts a database available to all police agencies across the country. If local police officers encounter these individuals in the aftermath of an incident, they now know to get them care first. They also know all the right people to call. Inspector Michael Brown, Mental Health Coordinator at the College of Policing, explains that understanding mental-health risks is key to all police work, not just suicide reduction.
“Everything we know about policing that goes wrong is because we don't know the individuals' backgrounds, and we don't know what's right for them given their history,” he says.
A recent Home Affairs Committee Report found that 20 to 40 per cent of police time involved an element of mental health. “Improving the information officers can access helps them select from their skills, and that seems to maximise the potential that officers can build a rapport,” he said. “Trust and empathy are crucial to resolving incidents without use of force.”
Emily says that the BTP officers' compassion also helped with her recovery. “If they had been over-forceful, that only adds to your distress,” she says. Years ago, she had incidents with police in which their use of force, or even just their apathy, deepened her instability.
Today, the BTP is not the only police force in Britain working with mental-health teams. Pilot programmes have cropped up in Cleveland, Leicestershire, Thames Valley and dozens of other localities. Many of these programmes are known as “street triages”, whereby police liaise with mental-health professionals on the other end of a direct helpline, stationed in their control rooms or, in some cases, patrolling with them in police cars.
One way to judge the success of street triages is through the rate of detention of mentally ill patients. In one street triage pilot in Oxfordshire, for example, the Thames Valley Police saw an 85 per cent reduction in the number of people with suspected mental-health issues who were held in police cells. With the help of mental-health nurses, these patients were instead taken directly to hospitals and other emergency health services.
“Triage is still very much in its infancy and it's a bit of a Marmite thing, people either love it or hate it,” says Inspector Jan Penny, mental-health lead for the Thames Valley Police.
“That's because some people see triage as police doing health-service work. For us, something we're very clear on is that police continue to be police officers.”
Both Smith and Inspector Penny believe that this system of health and police cooperation teaches officers how to effectively move people into care, not provide it. On the other side of the debate, some argue that police are already overexposed to mental-health issues, and health agencies should be stepping in earlier.
Either way, inter-agency cooperation on mental health is picking up speed. The launch of the Crisis Care Concordat of 2014, a joint agreement between key agencies that respond to mental-health crises, may be partially responsible. Many across health services and police say that it has vastly improved communication between the groups. And some police forces around the country are now exploring how they can incorporate BTP's mental-health practices into their own work.
As the BTP evaluates its own programme, it continues to work out the little kinks. When Emily recounts her own incident, she wonders why she was led to a station coffee shop to wait for an ambulance. It was relatively quiet, but she recognises that a more private space might have been more appropriate. However, police suites can often cause more distress than the privacy is worth.
In addition, nurses used to be stationed in the BTP control rooms, where they could respond to an incident in real time. Recently, they moved to BTP offices, where they are one more step removed from the incidents and the officers trying to address them.
The early evidence, though, suggests that the BTP's programme is working. Across the rail network, nearly six per cent of recorded suicidal incidents last year ended in suicide. Compare that with the one per cent of those on BTP-supported suicide prevention plans, where only 10 out of more than 1,100 took their lives. But despite the programme's success, the BTP's work is far from over. Last year, the BTP responded to nearly 6,000 incidents in which people showed suicidal behaviour. And nationwide, railway suicides continue to increase in line with the rising number of overall suicides.
As for Emily now, she hasn't had a crisis since that day in June. She spends her time volunteering with student nurses and mental-health workers, advising them from the perspective of a patient.
A few weeks ago, she saw Smith speak at a conference. She flagged him down in the crowd and asked if he would pass on a message to his officer, PC Mildinhall. He had saved her life, and she wanted him to know how grateful she was. Smith did pass on the message. He also asked Emily to come on board as a volunteer consultant. He is hoping that her input will improve how they work, and help bring those 10 suicides down to zero.
The Samaritans helpline is open 24 hours a day: 08457 909090