--- title: "Ms H Persistent Caller to Police and Ambulance Service" type: "pdf" year: "2011" canonical: "/projects/297" --- # INTRODUCTION Ms H is a 44 year old woman who lives alone. In October 1989 she gave birth to a baby girl who died the following January at 4 months old. Since this date she has suffered from depression. She has two daughters and two grandsons who visit her. Her daughters live locally enabling them to visit her easily. Ms H has historically persistently phoned various agencies including Police, North East Ambulance Service (NEAS), Fire Service, Mental Health Team, Crisis Team, Primecare, Samaritans, mail order companies, friends and neighbours reporting that she had either taken or was threatening and/or attempting to take an overdose. On occasions she would self harm by cutting her wrists, however these were not genuine suicide attempts (the cuts were mere scratches which either needed no medical attention or a small bandage) but behaviour indicative of her attention seeking diagnosis. # Table of Contents - [INTRODUCTION](#introduction) - [SCANNING](#scanning) - [ANALYSIS](#analysis) - [Problem Analysis Triangle](#problem-analysis-triangle) - [RESPONSE](#response) - [Acceptable Behaviour Contract (ABC)](#acceptable-behaviour-contract-abc) - [Anti-Social Behaviour Order (ASBO)](#anti-social-behaviour-order-asbo) - [ASSESSMENT](#assessment) - [- Police](#police) - [- North East Ambulance Service](#north-east-ambulance-service) - [- Primecare](#primecare) - [- University Hospital of North Tees](#university-hospital-of-north-tees) - [Proposed Joint Protocol between Cleveland Police and NEAS to deal with 999 Misuse](#proposed-joint-protocol-between-cleveland-police-and-neas-to-deal-with-999-misuse) - [Conclusion](#conclusion) ## SCANNING This issue was originally identified by the Neighbouring Policing Team Officer due to the high volume of calls received in to the Control Room directly from Ms H. Liaison between the Control Room POP Coordinator and Stockton District POP Coordinator led to the involvement of the Customer Care Officer at NEAS as this was the initial partner identified by the Police as also being in receipt of a high number of calls from Ms H. Police and NEAS often both responded to the same call. NEAS confirmed a number of calls in relation to Ms H came to them from Primecare, her Mental Health Team and Samaritans. NEAS also confirmed that Ms H was often transported to the University Hospital of North Tees (UHNT) as a result of these calls. Primecare is an out of hours Doctors surgery accessible by telephone to members of the public from 6pm-8am. Initially the call would be taken by a call taker and a clinician (either a nurse or doctor) would then assess the priority before contacting the patient and making an assessment. Calls can be resolved by advising the patient, referring to their own GP, a home visit by a doctor, call for an ambulance or referral to a dentist. Ms H would involve unlinked agencies reinforcing her attention seeking behaviour and would fully exploit the lack of multi agency involvement. Ms H is also highly manipulative and would take advantage of her friends and neighbours; if she had a problem with her house, money, family, friends etc she would contact them and inform them that she was intending to or had taken an overdose and concerned for her welfare they would contact the Police resulting in further attendances by the Emergency Services thus diverting them from their core duties. Research showed that Ms H was a continued problem for the Police, NEAS, Primecare, Samaritans, Mental Health Team, Accident and Emergency and Crisis Team and had been for a significant number of years. She was a continuous drain on both human and financial resources of all the agencies involved and had little regard for the subsequent effect her actions may have had on members of the public who were in greater need of emergency services. Ms H follows a routine pattern of offending behaviour which escalates when she is lonely. Firstly she will contact the Samaritans; however she is only entitled to an hour of their time a night due to her frequent service use. Ms H will then contact her Mental Health Team who will only speak with her for a further 20 minutes, again due to her frequent service use. Ms H will then contact the Police or NEAS who are available to her at all times. If Ms H does not obtain an immediate response to her original request from either Emergency Service she will then escalate her behaviour. Historically this has involved: - Walking along the main arterial carriageways within the Force area dressed in her white dressing gown in an attempt to raise alarm and distress to passing motorists who will subsequently contact the Police fearing for her safety. Ms H has historically walked up to 10 miles before she has been reported to the Police and has been found in different locations throughout the county. - On occasions when threatening to take her own life she has been found by Police standing on the pedestrian railings of a bridge clinging to a lamp post threatening to jump onto the motorway below. Police will then attend the location as reported by the caller and Ms H would often then be transported to hospital either by Police or ambulance for assessment. When subsequently assessed at the hospital Ms H will either refuse treatment, or tests reveal she has not in fact taken any medication to overdose. If tests reveal Ms H has taken medication it has not been possible to verify the amounts as to whether she had overdosed. As a result of this Emergency Services intervention Ms H will then have achieved her objective to satisfy her attention seeking behavioural needs i.e. human interaction. Since 2006 Ms H has resided in five different addresses in the Stockton area rented from private landlords who were registered with the local authorities Landlord Liaison Scheme. This scheme allows landlords to share information with each other and with the Police regarding their tenants. There were no issues in relation to her tenancy and her rent was paid regularly and up to date. # ANALYSIS ## Problem Analysis Triangle Research of the problem identified the offender in this case as Ms H, with the multi agencies involved in her case (NHS, Emergency Services, Primecare, Crisis Team etc) identified as the victims. It could be argued that members of the public could also be considered as victims as assistance from the above agencies may have been delayed or even deprived due to the amount of time involved in dealing with Ms H . The location was the home address of Ms H however her frequent moves continued to support her attention seeking behavioural needs, but the individual addresses did not appear to exacerbate her problems. When Ms H initially came to notice of all the services involved with her care, an independent response was provided and each service continued to operate independently of the others utilising in the main short term solutions to deal with Ms H's behaviour. This ultimately led to an adverse impact on Emergency Services provision as Ms H continued to exploit the lack of multi agency engagement. The short term solutions were initially focussed on dealing with Ms H as efficiently as possible at the time the incidents were occurring. This situation would be exacerbated by one agency having attended and dealt with Ms H's immediate medical needs, however, as a result of her lack of cooperation, the initial attending agency would then request another agency to attend and assist at that time or for follow up interventions. - The initial response prior to the multi agency approach was that both Police and/or NEAS attended the address in response to her call. This was not only costly to both Emergency Service providers but potentially could put the lives of other members of the public at risk. - Having attended to Ms H the problem was dealt with in the quickest way possible by all agencies so staff could focus on other aspects of their job. The reasons for her calls were never fully investigated and therefore resolved. - One consideration was for the Police to confiscate Ms H's dressing gowns for two weeks which resulted in her being unable to walk along the main arterial carriageways. However no power existed to seize the dressing gowns so they were returned to her with the result that she resumed this behaviour. - Other Police considerations in the early stages initially worked with Ms H being invited to the Police Control Room to observe staff taking emergency calls and emphasis being placed on the importance of not wasting police time. She was even presented with a certificate for her good behaviour; however this proved a short term solution to resolving the problem and with hindsight only succeeded in fulfilling her attention seeking behaviour. - An Informal Acceptable Behaviour Contract (ABC) had been agreed between the Police and Ms H in 2006, 2007 with the latest in April 2008. Their short term success was evident in the brief reduction of her calls. There were however difficulties in enforcing breaches of her ABC and it was deemed there was insufficient evidence to apply for an ASBO at that time as there was no evidence of harassment, alarm or distress caused to members of the public. - In July 2008 Police gathered more evidence regarding Ms H's behaviour and this included speaking to her neighbours where it was identified that Ms H caused numerous problems. Not only had she become abusive towards them, their main complaint was the disturbance during the night by the sound of the sirens from the Ambulance and Police cars attending to her calls. - Friends and relatives of Ms H were spoken to and the consensus of their opinion was Ms H's behaviour was escalating due to her successful manipulation of all the agencies involved with her and the lack of these relevant agencies working together to address her behaviour. - A multi agency meeting involving the Mental Health Team Psychiatrist, Ms H's Social Worker and Police POP Coordinators was arranged. Her medical diagnosis of Borderline Personality Disorder was explored and importantly this established that Ms H did in fact have the mental capacity to understand the impact of her actions and the resulting consequences. It was agreed that she had been extremely effective in manipulating agencies to secure her desired outcomes. - Criminal Offences were considered including 'Offences under the Communications Act 2003', however there was no proof that Ms H was lying or that it was her purpose to cause inconvenience, annoyance or anxiety and therefore this offence was discounted. - Whilst it was identified that she abused the services of the Samaritans, they were reluctant to participate fully in the multi agency approach in dealing with Ms H as they were a registered charity and their primary function was to support people in need. They did however agree with Ms H that they would only allow her to access the service for a maximum of one hour on the telephone. In order to research the problem further a scanning document was prepared using data from the Police, NEAS, UHNT and Primecare systems. - Police - Since 1 January 2004 to 31 August 2008 Police received 461 calls from Ms H. The majority of these calls resulted in the attendance of a Police Officer. During this period the estimated cost to the Police was $£ 34,965$ (approximately $£ 7,000$ per annum.) The calls were received mainly during a weekday night (peak times were between 2000 - 0400hrs and on Mondays and Fridays) but rarely on a weekend. However a significant decrease occurred on a Saturday when Ms H's daughters and grand children visited. Calls were rarely received between 0800 - 1600 hrs. - Primecare - During 2004 Primecare received minimal calls from Ms H. However during 2005 these calls increased to 56 calls in total and an unacceptable increase to 625 from 1 January 2006 - 31 December 2008. However Primecare were unable to calculate the cost of Ms H's calls due to the variation in their content. - North East Ambulance Service (NEAS) - From October 2006 (figures are not available before this date due to the merging of Ambulance Trusts) up to February 2009, NEAS has responded to Ms H on 163 occasions. This has amounted to 136 hours of crew time at a cost of $£ 23,674$ to the taxpayer. - Accident and Emergency Department, University Hospital of North Tees - From 2002 - 2004 Ms H attended UHNT A\&E Department on 54 occasions. However this increased to 49 attendances in 2005 alone at a minimum cost of $£ 2955$. There were 92 attendances from 1 January 2007 - 31December 2008 costing at least $£ 5,547$. This was based on her attendance alone and depending what treatment was given could have increased significantly. Figure 1 shows the number of reported incidents per month involving Ms H from 1 January 2008 to 28 February 2009. There is a clear pattern whereby if there is a demand for one agency then there is a correlating demand for all services. Calls for Service January 2008 - February 2009 ![img-0.jpeg](https://popdatasets.blob.core.windows.net/popdatasetmdimgs/11-28/img-0.jpeg) There was a reduction in calls in April 2008 for a period of approximately six weeks. This was initially thought to have been due to the implementation of the ABC agreed between Ms H and the Police. After speaking to neighbours however it was later identified that the reduction in calls to the Emergency Services was due to the fact that Ms H had family residing with her. The calls to the Emergency Services resumed when her family moved out, however there were no calls on a Saturday evening when she was babysitting her grandchildren. # RESPONSE The overall plan of action was to reduce the amount of calls to all the partner agencies in particular the Police and NEAS and thus reduce the subsequent attendance at UHNT. It was agreed that a joint approach be taken in respect of all agencies in response to Ms H . A Multi-Agency Meeting was attended on 23 July 2008 by Police, NEAS, A\&E, ASB Team, Mental Health and Primecare. All partners agreed to share information on Ms H so there would be a clear understanding of the impact Ms H had on all the services and the following initial outcomes were agreed: - NEAS agreed that if they attended in response to Ms H self harming they would not later contact the Police to request a follow up visit to check her welfare. - Police agreed to liaise with Ms H's friends and neighbours to obtain statements from them in relation to the Anti Social Behaviour resulting from her contacting the Police and NEAS. - Police to liaise with Ms H's Landlord in respect of her tenancy agreement. - Stockton Borough Council ASB Team agreed to consider applying for an ASBO. - Stockton Borough Council agreed to supply diary sheets to neighbours which would be delivered by the Police. - All agencies provided evidence of the cost responding to Ms H . - Primecare agreed to consider carefully if an ambulance was required and would only contact NEAS if they truly believed it necessary. They would refer her calls to their medical team. - The Mental Health Team agreed to minimise their period of engagement with Ms H in order to prevent the fuelling of her attention seeking behaviour. It was also agreed an ambulance would not be requested on her behalf should she attempt suicide by overdose as the Mental Health Team believed Ms H was capable of securing her own rescue by contacting the relevant service herself. In their view the likelihood of Ms H taking her own life successfully was minimal unless it was due to misadventure. - The disconnection of her telephone line was considered but dismissed due to her vulnerability issues. Ms H has other medical problems which may require her to genuinely contact the Emergency Services. - An Acceptable Behaviour Contract was agreed and signed by Ms H on 29 October 2008 in an attempt to reduce the problems she was causing. - A draft protocol was introduced between NEAS and Cleveland Police to deal with other persistent callers. - Ms H enrolled with the local library with the assistance of the Police which allowed her to use the library computers including "chat rooms" where Ms H could contact others at times when she was lonely and seeking human interaction. - Ms H has a gifted flair for "cross stitch" and she was commissioned by a Police Officer to produce some cross stitch which gave her focus and occupied her time productively. - Police liaised with Ms H's landlord and it was established that he also had problems with her continually phoning him in relation to the house she rented from him and as a result he issued a notice of intent to seek repossession of the property. # Acceptable Behaviour Contract (ABC) As a result of further evidence from NEAS, Police, UHNT, Primecare and neighbours which supported the fact that Ms H's actions caused harassment, alarm and distress including financial distress to these services the Local Authority ASB Team agreed to impose another ABC which was agreed between Ms H and the Local Authority on 29 October 2008. The ASB team reviewed the evidence and concluded there was sufficient evidence to support an ASBO if necessary. On Tuesday 8 December 2008 a joint publicity campaign was conducted at UHNT involving the NHS, NEAS and Police to promote the fact that abusing the 999 system would not be tolerated and that all the involved agencies were working together in partnership to identify and resolve the issue of people who persistently abuse the Emergency Services. The local media publicised the event which was timed to coincide with the run up to Christmas when research showed an increase in the abuse of the Emergency Services. At the six month conclusion of the ABC, a significant increase in the volume of Ms H's calls was apparent and it was then decided that it was appropriate to obtain an Anti Social Behaviour Order to address Ms H's behaviour. # Anti-Social Behaviour Order (ASBO) On 14 July 2009 an interim ASBO was granted by Teesside Magistrates Court and a subsequent full ASBO was granted, valid until 5 November 2012. ## ASSESSMENT Initially the Acceptable Behaviour Contract signed by Ms H made on 29 October 2008 resulted in a significant reduction in the calls made to all agencies. However, Figure 2 shows the number of calls to all services increased at the six month conclusion of the ABC. Between the expiry of the ABC at the end of April 2009 and the full ASBO being obtained on 14 July 2009 there was a significant increase in calls, although the volume had not increased to levels seen prior to a multi agency approach being adopted. Calls for Service March 2009 - February 2010 ![img-1.jpeg](https://popdatasets.blob.core.windows.net/popdatasetmdimgs/11-28/img-1.jpeg) # - Police Police have only received 2 calls from Ms H from 29 October 2008 to 28 February 2009 however both calls were genuine. Officers were careful in writing the Acceptable Behaviour Contract so as not to deter Ms H from contacting any of the Emergency Services in relation to real incidents or emergencies. It is of note that during this period was the anniversary of the death of her which showed no increase in the calls to the police. Historically this has been a difficult period for Ms H, usually resulting in significant crisis and therefore an increase in calls. There was an increase in calls at the end of the ABC, however after the ASBO was granted the calls reduced significantly and were of a relevant nature. ## - North East Ambulance Service The North East Ambulance Service have not received any calls from Ms H, however they have received five calls from third parties, three of which were genuine complaints. On the 20 January 2009 a third party complained to NEAS that Ms H had attended the offices of the Prime Care Trust complaining of a headache and vomiting. However, on this occasion she breached her ABC by leaving prior to the attendance of the ambulance and refusing treatment thus inciting a third party to call the ambulance when it was not necessary. The fifth occasion was also from a third party PCT as Ms H had complained of a back and wrist injury and was transported to hospital. The cost to NEAS on these occasions was $£ 779$. There have only been two calls to NEAS from the issue of the ABC to 1 March 2010 ## - Primecare Primecare have received 28 calls since the imposition of the ABC. However these calls were either in relation to actual illnesses or for advice on genuine medical matters. There have been no reports of self harm or threats to self harm. In July 2009 Ms H breached her ASBO by contacting Primecare several times within a 24 hour period after she reported to them that she had swine flu, then requested a time of arrival of a doctor to give her advice and then when she had received medical treatment recontacted Primecare again to say she no longer thought she had swine flu. Ms H later pleaded guilty at court and was given an absolute discharge. As of 1 March 2010 Ms H has only made four calls to Primecare since the breach of her ASBO. ## - University Hospital of North Tees UHNT have also reported a reduction in attendances of Ms H. She has only attended the hospital on four occasions since she signed her ABC until the end of February 2009 in contrast to 23 attendances for the same period the previous year. She has attended hospital on three occasions since the ASBO was granted upto 1 March 2010 at a total cost of $£ 181$. ## Proposed Joint Protocol between Cleveland Police and NEAS to deal with 999 Misuse As a result of this initial early success, Cleveland Police and NEAS are continuing to develop further guidelines on how to deal with people such as Ms H. The following steps have been suggested: - NEAS to establish a protocol for dealing with persistent callers (which includes establishing a formal database within their control room, sending out warning letters, disconnecting telephone lines \& prosecution). - In exceptional circumstances NEAS to contact Police Control Room if they have a significant problem involving a person abusing their service. A suitable response may be to send a Neighbourhood Policing Team Police Officer to speak to the caller as soon as practicable and warn them of the consequences of their actions. - Where a persistent caller is identified as a problem to both the Police and NEAS, joint working practices will include NEAS producing a schedule of calls made by the caller, copies of signed incident reports, a copy of the letter sent by NEAS to the caller, and a statement to the Police to proceed with action to be taken against the caller. This may involve the Local Authority Anti-Social Behaviour Team. - Continued tailored support to the offender will be requested from appropriate agencies such as Mental Health Services and Samaritans. # Conclusion The experience of dealing with Ms H has allowed formalised working practices between Cleveland Police and other agencies to be adopted and utilised when dealing with persistent callers who contact the Emergency Services inappropriately. Information relating to the persistent caller is shared between relevant agencies and this has resulted in a coordinated response to this and future problems. The omission of a coordinated approach between relevant agencies with regard to repeat callers resulted in resources being ineffectively used and often wasted in attempting to 'quick fix' this problem. Clearly agencies did not liaise with one another, absorbing the problem in isolation and responding on an individual basis. Ms H was fully supported by appropriate agencies throughout the process, however she made her own choices with 'capacity' with regards to committing acts of anti social behaviour. Positive action via the courts has been the ultimate proven successful outcome in this case to address the unacceptable behaviour of Ms H . This case has been used as an example of best practice for other similar cases; however it is acknowledged that each case is to be addressed on its own merits due to the differing issues surrounding the persistent caller. One or more of the following problems are usually prevalent: drug \& alcohol abuse, mental health problems, learning difficulties, poor social skills and isolation and it is acknowledged by the Health Sector that a more holistic approach to supporting people is required as opposed to the present situation where separate interventions are provided for each diagnosis. To date 31 May 2011 Ms H has not used services inappropriately.