Healthcare issues of detainees in police custody in London, UK

Provision of forensic healthcare services for police custodial settings in England, Wales and Northern Ireland: Current practice and implications for other services?

Provision of forensic healthcare services may affect patient safety and criminal justice outcomes. We reviewed models of delivery for services in police custody in terms of cost, types of healthcare professionals and their minimum required experience, training and qualification. Relevant information was requested under the Freedom of Information Act from all police services in England, Wales and Northern Ireland. Additional information was sought from the London Ambulance Service and the Metropolitan Police Service. A third of respondent police services refused to provide the requested information and only a small minority answered the questions in their entirety. Many police services cited excessive cost and commercial interests as reasons for not providing the information. A marked variation in models of forensic healthcare provision across police services which responded was identified. London Ambulance Service call-outs to Metropolitan Police Service custody suites for those arrested varied from 0% to 3.8%. There is substantial inconsistency and variability of information on forensic healthcare services in police custody. A standardised national dataset of all aspects of police custodial healthcare (irrespective of by whom such services are provided) should be established. We advise that the Association of Police & Crime Commissioners, College of Policing the National Police Chiefs' Council and NHS England Health and Justice engage on these matters and work with the Faculty of Forensic & Legal Medicine, the United Kingdom Association of Forensic Nurses and Paramedics, and the College of Paramedics to restart the transfer of all police custodial healthcare services to the National Health Service.

Complaints against health care professionals providing police custodial and forensic medical/health care services in England, Wales and Northern Ireland - what do we know?

Awareness of the nature and frequency of complaints against health care professionals working in police custodial health care services could provide opportunities to improve patient safety. To explore this freedom of information requests were sent to police services in England, Wales and Northern Ireland, to professional regulatory bodies and to the Independent Office for Police Conduct. Eighty-seven percent of police services responded but only a minority provided complete responses, with data not being held, or not being held in an easily retrievable format, being provided as reasons. The nature and frequency of complaints were similar to a previous 2017 study, suggesting a failure to learn lessons from the investigation of complaints and implement change in clinical practice. No evidence of an accessible complaints handling and recording procedure was provided across the police services surveyed. Regulatory bodies provided some information on the nature of complaints made against doctors and nurses working in police custodial settings, but that for paramedics was unable to do so. It is recommended that the communication loop between police services, those bodies providing health care and forensic medical services and regulatory bodies needs to be closed. A common reporting system or the application of established complaints handling procedures and reporting structures, which could be achieved by transferring these services to the National Health Service, may enhance patient safety in police custody.

Structures, processes and outcomes of health care for people detained in short-term police custody settings: A scoping review

BACKGROUND

People detained in short-term custodial settings can require health care that may necessitate transfer to an Emergency Department (ED). What and how health care is delivered to detainees in short-term custodial settings may influence their health outcomes.

OBJECTIVE

The aim of this scoping review was to synthesise and critically appraise the evidence on health care delivered to detainees in short-term custody settings.

DESIGN

A scoping review was undertaken. Five online databases (CINAHL, PubMed, Medline, Embase and Criminal Justice Database) were searched from January 2010 to May 2020. Data extracted pertained to the structures, processes and outcomes of health care delivery. The Mixed Methods Assessment Tool was used to quality appraise the studies. Deductive analysis was used to sort the findings into structures, processes and outcomes of health care delivery and then thematic analysis was undertaken to synthesise these findings.

RESULTS

In total, 37 studies with varied designs were included in this review; 3 randomised control trials, 4 quantitative comparative studies, 21 quantitative descriptive studies, 8 qualitative studies and 1 mixed methods study. Studies were mainly from westernised countries. The quality of evidence varied across studies. Health care delivery structures had a strong focus on the identification of mental illness, with processes predominantly comprising health assessment screening on arrival to the short-term custodial setting. Outcomes (at the detainee and organisation level) included increased identification of substance misuse issues and improvement of health conditions, alongside inadequate assessment/identification of physical and mental health issues for detainees.

CONCLUSION

Gaps in evidence identified limited international perspectives as most studies originated from the US, a focus on detainee conditions/symptoms and limited long-term research within the area of health care in short-term custodial settings. Literature regarding health care delivery in short-term custodial settings focused predominantly on mental illness identification. Understanding the nature of health care delivery in short-term custodial settings further through research into specific roles such as the custody nurse is required to develop targeted interventions that address the needs of the detainee on a comprehensive level.

Identifying vulnerability in police custody: Making sense of information provided to custody officers

Vulnerable individuals frequently come into contact with the criminal justice system with those with mental health disorders over-represented in custody. Therefore, it is crucial to identify vulnerability in order to ensure the appropriate safeguards can be put in place. Research has documented that this is problematic and can be influenced by a number of factors. The current study, therefore, aimed to understand how custody officers in England and Wales made sense of different types of information presented to them, the impact that it had on their initial disposal option and whether there was a difference in police force area. Six case scenario vignettes containing different types of vulnerability were developed and disseminated. A total of 237 custody officers from 25 police forces participated. Results highlighted that custody officers were more likely to obtain a mental health assessment in all case scenarios, except if the individual displayed comprehension difficulties - custody officers would instead seek to implement the services of an Appropriate Adult. In addition, differences between police force areas were observed. Police forces in the North of England were the least likely to obtain the assistance of an Appropriate Adult when presented with a vulnerable suspect compared to other police force areas. This suggests fundamental differences in the disposal options preferred between police force areas and has implications for the treatment of vulnerable individuals in police custody.

The prevalence of mental illness and unmet needs of police custody detainees

BACKGROUND

Internationally, there is evidence of high rates of mental disorders amongst police custody detainees but this literature is limited, and there has been little research into the unmet needs of police detainees in the UK, or elsewhere. Such research could support better focussed interventions for improving health and recidivism outcomes.

AIM

To examine psychiatric and developmental morbidity amongst police detainees, and ascertain differences in need between morbidity categories.

METHOD

We used a cross-sectional study design and interviewed a 40% sample of people entering police custody in one South London police station over a 2-week period. A series of standardised measures was administered to screen for the presence of mental illness, general health and social care needs.

RESULTS

A cohort of 134 people was generated, of whom nearly one-third (39, 29%) had current mental illness (major depression and/or psychosis); more had a lifetime diagnosis (54, 40%). Just under a fifth met the threshold for post-traumatic stress disorder (11, 8%). Clinically relevant alcohol or daily cannabis use affected about one quarter of the sample. Twenty-one percent (or 28) screened positive for personality disorder, 11% (or 15) for attention deficit hyperactivity disorder and 4% (6) for intellectual disability. Nearly one-fifth (24, 18%) were at risk for suicide. Those with psychosis, and those deemed at risk for suicide, had the highest levels of unmet need and, indeed, overall need. The most frequent unmet need was for accommodation.

CONCLUSION

Our findings not only confirm high rates of mental health problems amongst police detainees but also demonstrate their high risk of suicide and high levels of unmet need, especially as regards accommodation. This underscores the need to provide mental health services in police stations, to help identify and resolve these issues at this early stage in the criminal justice system. Extending accommodation capacity to help some arrestees may help to save lives and interrupt cycling through the criminal justice system.

Custody early warning scores; Do they predict patient deterioration in police custody?

This paper analyses the results of a three month trial based in a police custody suite, where we assigned a value; using the recently developed Custody Early Warning Score, to detainees arriving into police custody, as part of their 'booking in' process. We then compared this to the more established National Early Warning Scoring system and then looked at the predictive accuracy of these two systems and how they correlated to one another, when applied to three different clinical groups of detainees in police custody. Police Custody Sergeants and Custody Detention Officers continue to experience difficulties in identifying those detainees with health care needs; be they subtle, emerging or more evident. The introduction of a 'track and trigger' physiological scoring system has been seen to reduce morbidity in health care settings and so the adoption of an altered custodial version of such a system is an effort by some police forces to do likewise. Recent innovations in police custody have focussed on identifying and appropriately referring those detainees with mental health needs. There is a lack of research that examines the physical health needs of the custodial population and the risks that they might present. With detainee deaths and serious adverse events continuing to occur in police custody, forces are looking at ways to identify risk early on in the custodial process, to reduce such high profile occurrences. Police use of the Custody Early Warning Score system, is one effort to try and identify and reduce this risk, early on in the custodial process.

OBJECTIVE

In an increasing number of police custody suites, the Custody Early Warning Score system has been, added to the normal, standardised police risk assessment process. This 'track & trigger' system has been adapted to the custody environment and is conducted by non-medical detention staff upon detainee arrival, in order to identify detainee morbidity and mortality risk. We wanted to test the predictive accuracy of this system at identifying detainee health need and prioritisation. We also wanted to know how well this tool correlated to another well-established monitoring tool and how accurate these two systems are at pre-empting the medical emergencies and hospital referrals that occur in police custody.

RESULTS

1'163 detainees were assessed by medical staff over a three month period, with staff blinded to the assigned scoring. 276 of these were identified as requiring further clinical assessment following this scoring with 29 of the 33 patients referred to hospital by medical staff, also scored, with some declining assessment or were serious enough to abandon scoring. Whilst we found a small correlation between increased scores and referral to hospital; we found that there was little correlation between assessment scores in general and the need for referral to hospital. We also found that most clinical risk was associated with lower or low scores.

CONCLUSIONS

The scoring systems that we assessed were not sensitive enough to identify health need in the detainee population, due to frequent, altered physiological parameters. Life threatening conditions have low assessment scores, not reflective of the seriousness of medical conditions, nor the potential for rapid deterioration. Such scoring systems add little to the risk assessment process, with low scores allowing for complacency and a false reassurance, when using a system designed for very different circumstances.

Mental health in the criminal justice system: A pathways approach to service and research design

BACKGROUND

Care pathway approaches were introduced into health care in the 1980s and have become standard international practice. They are now being introduced more specifically for health care in the criminal justice system. Care pathway delivery has the theoretical advantage of encouraging a whole-systems approach for health and social care within the criminal justice system, but how well is it supported by empirical evidence?

AIMS

The aim of this study is to review the nature and extent of evidence streams supporting health care delivery within interagency pathway developments since 2000.

METHOD

We used an exploratory narrative method to review the nature and extent of evidence streams supporting health care delivery within interagency pathway developments since 2000. The available literature was reviewed using a keyword search approach with three databases: PubMed, Medline, and Google Scholar.

FINDINGS

Research in this field has covered police custody, courts, prisons, and the wider community, but there is little that follows the entire career through all these elements of offender placement. Main themes in the research to date, regardless of where the research was conducted, have been counting the disorder or the need, development and evaluation of screening tools, and evaluation of clinical intervention styles. Most evidence to date is simply observational, although the possibility of conducting randomised controlled trials of interventions within parts of the criminal justice system, especially prisons, is now well established.

CONCLUSIONS

Access to health care while passing through the criminal justice system is essential because of the disproportionately high rates of mental disorder among offenders, and the concept of structured pathways to ensure this theoretically satisfying, but as yet empirically unsupported. Further, substantial cuts in services, generally following government economies, are largely unresearched. Considerable investment in new possibilities, driven by both pressure groups and government, tend to be informed by good will and theory rather than hard evidence and are often not evaluated even after introduction. This must change.

Adolescent arrestees detained in police cells: an observational study in the Paris, France, area

OBJECTIVE

Custody conditions in police cells are often demeaning and considered inappropriate for human beings. The detention of young adolescents in police custody has received little attention. Our study aimed to describe the characteristics of adolescents under 18 detained in custody.

METHODS

We studied all arrestees aged 13-17 examined in 1 year (January 01-December 31, 2014) in a suburban district near Paris. We evaluated the proportion of adolescents under 18 among all arrestees detained in custody and their medical history, addictive behaviors, perceived health status, and opinion on custody.

RESULTS

Arrestees aged 13-17 accounted for 1859 individuals. They were predominantly males (94%) and accounted for 19% of all examinations in custody. Nearly half of the arrestees aged 13-15 (42%), and two thirds of those aged 16-17 (65%) had been previously detained in police cells. Somatic and psychiatric disorders were reported by 7% and 4%, respectively, of arrestees aged 13-17. Alcohol, tobacco, and cannabis consumption were reported by 5%, 24%, and 12%, respectively, of arrestees aged 13-15. These proportions were lower than the 16%, 50%, and 35%, respectively, reported by arrestees aged 16-17 (p < 0.0001). Assaults were reported by 18% of arrestees aged 13-17. They had a fair, bad, or very bad opinion on custody in 43% of cases.

CONCLUSION

The detention of adolescents in police stations is commonly associated with assaults at the time of arrest. High proportions of adolescent arrestees smoke tobacco or cannabis. We suggest that the medical examination in custody could be an opportunity for adolescents to initiate access to health care.

Mental illness and the provision of mental health services in prisons

INTRODUCTION

Around 11 million people are held in prisons internationally, and criminal justice systems are overburdened with a high prevalence of multiple psychiatric disorders. In England and Wales over 200 000 people enter prisons each year, and in many cases, this facilitates their first contact with mental health services.

SOURCES OF DATA

Research, evaluations, government reports and independent reviews.

AREAS OF AGREEMENT

Screening, Triage, Assessment, Intervention and Re-integration (STAIR) are necessary components of prison mental health provision, offering an opportunity to improve the wellbeing of a complex population.

AREAS OF CONTROVERSY

There are serious problems with service provision across many parts of the world, with human rights abuses occurring in some States. Screening and service delivery models still require substantial development. In England and Wales, self-harm, self-inflicted deaths and violence are increasing.

GROWING POINTS

Introducing comprehensive mental health models throughout prisons would offer a massive public health initiative, providing new services for the socially disadvantaged. A rights-based framework would be useful in ensuring systemic improvements, especially in low and middle-income countries.

AREAS TIMELY FOR DEVELOPING RESEARCH

Mechanisms for screening and triage, specific interventions across a broad range of conditions, and practical re-integration models, should be submitted to research across international sites.

A record linkage study on former police detainees who died in Amsterdam between 2013 and 2015

BACKGROUND

Police detainees are known to have inferior health. This study identifies the number of former police detainees who received medical care among deaths examined by forensic physicians and presents their death characteristics.

METHODS

We included all deaths that were examined by forensic physicians of the Public Health Service Amsterdam from 2013 to 2015. Patient files of subjects were scanned for the presence of a prior medical consultation in the police cell and death characteristics were collected from post-mortem examination reports. We performed statistical analyses to discover what characteristics at post-mortem examination were associated with a prior consultation in the police cell.

RESULTS

We identified n = 2618 subjects that met the inclusion criteria. Eight percent of subjects had one or more medical consultation(s) in the police cell in a mean follow up time of 4.8 (±3.0) years. No difference was found in the share of unnatural deaths between subjects with and without a prior consultation (68%), but distribution of death causes differed significantly. Male gender OR 2.3 (p < 0.001), age OR 0.98 (p < 0.001), unspecified unnatural dead OR 1.8 (p = 0.002), crime related dead OR 2.2 (p = 0.012) and accidental drowning and submerging death OR 4.6 (p < 0.001) were independently associated with the presence of an earlier consultation in the police cell.

CONCLUSION

Our data suggest that a small percentage of police detainees seen by forensic physicians for provision of medical care are also examined after death by these physicians, typically young males who seem to display risk-taking and criminal behavior resulting in unnatural dead.

The health of female arrestees in police cells: A descriptive study

INTRODUCTION

Little information is available regarding the medical status and health care needs of female arrestees. Our objective was to evaluate the perceived health and somatic or psychiatric disorders reported by female arrestees in police cells.

MATERIAL AND METHODS

We conducted an observational study in a regional reference department of forensic medicine in France. We studied female arrestees examined in police cells (01/01/2013-06/30/2013). Data were collected regarding individuals' medical characteristics, addictive behaviours, and perceived health status, as well as reported assaults or recent traumatic injuries. We recorded medical decisions regarding fitness for detention in police cells.

RESULTS

A total of 438 women (median age, 29; range, 13-67) accounted for 5% of the 7408 examined arrestees. Females considered their overall health as good or very good in 314/395 cases (70%). Women reported chronic somatic or psychiatric disorders more frequently than men (89/379, 23% vs. 757/6,135, 12%, p < 0.001 and 59/379, 15% vs. 392/6319, 6%, p < 0.001, respectively). Daily tobacco consumption and cannabis use were reported by 255/403 (63%) and 98/438 female arrestees (22%), respectively. Physical assaults were reported in 113/415 cases (27%). Female arrestees were considered fit for detention in 92% of cases. Among 24 pregnant arrestees, 6 (25%) were unfit for detention, 2 (8%) were fit for custody during daytime only and 16 (67%) were fit for detention if certain conditions were met.

CONCLUSIONS

Detention in police custody involves a minority of females. Females are older and report somatic or psychiatric disorders more frequently than males.

Reconciling mental health, public policing and police accountability

The paper evaluates a range of policy documents, parliamentary debates, academic reports and statutes in an attempt to contextualise the condition of mental health policing in England and Wales. It establishes that mental health care plays an important role in public policing and argues that police organisations need to institute urgent reforms to correct a prevailing culture of complacency. An unethical cultural attitude towards mental health care has caused decision-making and the exercise of police discretion to be neither well informed nor protective in many cases, resulting in the substandard treatment of people with mental health problems. The paper argues that changes introduced by the Policing and Crime Act 2017 and the revised College of Policing mental health guidelines do not go far enough and that more extensive root-and-branch reforms are needed.

Contextualising health screening risk assessments in police custody suites - qualitative evaluation from the HELP-PC study in London, UK

Background

In the UK, police custody officers have a responsibility to screen for health morbidity and vulnerability among detainees. This study aimed to develop an understanding of the barriers to performing effective health screening in police custody suites, understand the impact of screening tools on practice within the custody suite, and to identify factors that could hinder or facilitate the future implementation of a new screening intervention in this environment.

Methods

A qualitative study was conducted alongside a quantitative evaluation of a novel screening tool. Qualitative methods included observation of the custody environment, semi-structured interviews with police staff, and elicitation of comments from detainees about their experiences of screening. Data were analysed inductively using thematic analysis. Normalization Process Theory (NPT) was used to inform data collection and as a framework for higher level analysis of findings.

Results

Five overall constructs were identified that develop understanding of the integration of health screening within custody: the workability of risk assessment screening tools; the effect of the custody environment and the people therein; shifts in professional roles and interrelationships amongst staff; cultural responses to risk and liability in police work; how infrastructure, knowledge and skills can impact on detainee safety.

Conclusions

Health and risk assessment screening in police custody is a complex and demanding activity which extends beyond the delivery of a screening tool. Professional roles, the demanding environment and police culture impact on the overall process. Recommendations for improved integration of health and risk assessment screening in wider police custody practice are proposed.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5271-6) contains supplementary material, which is available to authorized users.

Screening for psychiatric morbidity in police custody: results from the HELP-PC project

Aims and method

To ascertain the efficacy of custody health screening for mental disorders. We assessed a sample of detainees for the presence of mental disorders and the need for an appropriate adult. The assessments were carried out using pragmatic interviews and examinations supported by structured tools. Where possible, we attributed a probable clinical diagnosis based on the information available to us. The need for an appropriate adult was judged based on this information and capacity assessments.

Results

Existing screening procedures missed a quarter of cases of severe mental illness and moderate depression; they also failed to detect about a half of those at risk of alcohol withdrawal and 70% of those at risk of withdrawal from crack cocaine. The need for an appropriate adult was not recognised in more than half of cases.

Clinical implications

Consideration should be given to modifying police screening procedures for mental and associated disorders so that detainees receive the appropriate attention.

Social vulnerabilities and health conditions of arrestees in the Greater Paris area, France, in 2013: a multicentre cross-sectional study

OBJECTIVE

The aim of this study was to describe the health and social conditions of arrestees, as compared to the general population.

METHODS

We studied a sample of 600 adult arrestees in three locations in the Greater Paris area, prospectively included (February-May 2013). A descriptive analysis has been performed, then prevalence was estimated using an indirect standardisation according to age, based on data from a population-based, representative survey in the same area.

RESULTS

Arrestees had a median age of 31 years; 92% were males. As compared to the general population, arrestees had a lower level of education (8.6 vs. 7.6%, p < 0.001), were more frequently unemployed (42.0 vs. 11.9%, p < 0.001) and in a difficult financial situation (43 vs. 11%, p < 0.001) and had less significant social support (48.1 vs. 87.9%, p < 0.001). They reported also more frequently a chronic health condition (54 vs. 36%, p < 0.001) and a limited health insurance coverage (36 vs. 15%, p < 0.001).

CONCLUSION

Comparative analysis of male arrestees and males from the general population showed that the former had worse social and health conditions. These results argue for widespread medical interventions on all arrestees. Medical examination during detention could act as a gateway to health care and social support.

Self-reported Mental Health Issues Among Arrestees in the Paris, France Area

We studied (May-September 2014) all arrestees who reported mental health issues during the medical examination performed by a forensic physician for the assessment of fitness for detention. Among 4814 arrestees, 420 (9%) reported a current mental health issue. The suspected crimes among arrestees reporting a current mental health issue were more often related to violent behaviors (physical assault, 23% vs. 16%, p < 0.001, sexual assault, 3% vs. 1%, p = 0.01) and less often drug offenses (18% vs. 29%, p < 0.001). Among arrestees reporting mental health issues, 80% reported psychiatric or psychological care, of whom 33% reported previous mental health care. Decisions of unfitness for detention were more frequent among arrestees reporting mental health issues than in other detainees (3% vs. 1%, p < 0.001). The high proportion of patients with interrupted mental health care among those reporting mental disorders suggests that the medical examination during custody could be a significant opportunity to restore psychiatric care.

In custody deaths of men related to mental illness and substance use: A cross-sectional analysis of administrative records in Ontario, Canada

Highly publicized incidents of in-custody deaths have drawn attention to the well-being of individuals who are held in custodial settings and have contributed to questions surrounding the role played by mental illness and substance use. The data for this descriptive study consist of administrative records from the Office of the Chief Coroner of Ontario. Section 10(4) jury verdicts filed from January 1, 1996 through December 31, 2010 were drawn for analysis. The final sample includes 478 males who died while in custody. Logistic and multinomial regressions were conducted to assess how a history of mental illness and substance use is related to deaths in custody and how those deaths vary across custodial jurisdictions. Approximately half of all deaths in custody occurred among those with a history of mental illness or substance use and those deaths disproportionately occurred in local police or provincial custody, compared to those held in federal custody. Further, the joint effects of a co-occurring history of mental illness and substance use were found to be statistically significant with the strongest effects observed in local police custody. The results from this study underscore concerns surrounding the well-being of individuals with a history of mental illness or substance use and who come into contact with the criminal justice system. With more offenders presenting with complex mental-health and substance-use problems, the implications for local police become apparent in the context of developing policies and practices directed towards preventing deaths.

Complaints against health-care professionals providing police custodial and forensic medical/health-care services and sexual offence examiner services in England, Wales and Northern Ireland

Complaints management is an integral component of good clinical governance and an essential contributor to patient safety. Little is known about complaints against health-care professionals (HCPs) in police custodial settings and sexual assault referral centres. This study explored the frequency with which complaints are made against such HCPs working in England, Wales and Northern Ireland. It explored the nature of those complaints and the procedures by which they are investigated. Relevant information was requested from all police services in England, Wales and Northern Ireland; professional regulatory bodies; and the Independent Police Complaints Commission under the Freedom of Information Act (FOIA). Eighty-nine per cent of police services responded to the FOIA request. However, only a minority of these provided detailed information. Many police services cited the provision of health-care services by external providers as the reason for not holding information upon complaints. There was no evidence of any upward trend in the numbers of complaints over the study period. Delayed response to a request for attendance, incivility, medication issues and issues regarding the quality of reports and evidence were amongst the most common types of complaints described. A small number of responders provided copies of the disciplinary procedures used to manage complaints against HCPs. Significant heterogeneity exists in respect of complaints handling procedures across custodial and forensic medical/health-care services and sexual offence examiner services. An opportunity to identify learning for improvement is being missed as a result of the absence of standardised complaints handling procedures.

Confidentiality & consent in police custody: General principles

The care of detainees (prisoners) in police custody has had much focus in recent years. The nature of the role of the doctor or other healthcare professionals within the police custodial setting may often be subject to conflicts, but their respective duties as healthcare professionals should generally overide any police or forensic issue that may be relevant. The laws or rules or statute that govern doctor, nurse or paramedic practice may vary from country to country, but the broad principles of healthcare ethics are universal and have been formulated not only by national healthcare regulatory bodies but by international organizations such as the World Medical Association. This article discusses in particular the duties of consent and confidentiality within the police custodial setting, giving examples of where conflicts may arise, and how they should be dealt with.

Police custody health care: a review of health morbidity, models of care and innovations within police custody in the UK, with international comparisons

This paper is a scoping review of the available evidence regarding health care issues in police custody. It describes the types and prevalence of health disorders encountered in custody and provides an overview of current practice and recent innovations in police custody health care. In contrast to the health of prisoners, the health of police custody detainees has, until recently, received little academic or clinical attention. Studies on health care in police custody identified for this review are limited to a few geographical jurisdictions, including the UK, continental Europe, North America, and Australia. There are significant health concerns among police detainees including acute injury, chronic physical health problems, mental and cognitive disorders, and the risks associated with drug and alcohol intoxication or withdrawal. There is some evidence that deaths in police custody have reduced where attention has been paid to the latter issue. Police personnel continue to experience difficulties identifying detainees with health issues relevant to their safe detention, but research shows that the use of evidence-based screening tools improves detection of such morbidities. Innovations in police custody health care mainly relate to detainees with mental disorders, including improved identification of illness, timely access to mental health services, the protection of the rights of mentally disordered detainees, and the diversion of mentally disordered persons from the criminal justice system into appropriate health and social care interventions. There is a lack of rigorous research relating to interventions for physical health problems, protecting those at risk of substance withdrawal, and detainees with preexisting or peri-arrest injures. Research to improve the health of police custody detainees requires greater priority, focusing on case identification and service redesign to address high levels of morbidity and to facilitate health promotion and prevention activities.

Can deaths in police cells be prevented? Experience from Norway and death rates in other countries

PURPOSE

To describe the changes in death rates and causes of deaths in Norwegian police cells during the last 2 decades. To review reports on death rates in police cells that have been published in medical journals and elsewhere, and discuss the difficulties of comparing death rates between countries.

METHODS

Data on deaths in Norwegian police cells were collected retrospectively in 2002 and 2012 for two time periods: 1993-2001 (period 1) and 2003-2012 (period 2). Several databases were searched to find reports on deaths in police cells from as many countries as possible.

RESULTS

The death rates in Norwegian police cells reduced significantly from 0.83 deaths per year per million inhabitants (DYM) in period 1 to 0.22 DYM in period 2 (p < 0.05). The most common cause of death in period 1 was alcohol intoxication including intracranial bleeding in persons with high blood alcohol levels, and the number declined from 16 persons in period 1 to 1 person in period 2 (p = 0.032). The median death rate in the surveyed Western countries was 0.44 DYM (range: 0.14-1.46 DYM).

CONCLUSION

The number of deaths in Norwegian police cells reduced by about 75% over a period of approximately 10 years. This is probably mainly due to individuals with severe alcohol intoxication no longer being placed in police cells. However, there remain large methodology difficulties in comparing deaths rates between countries.

The health of older arrestees in police cells

BACKGROUND

detention in the harsh conditions of police cells can be a traumatic experience, even for young healthy individuals. It is thus legitimate to question the detention of elderly people.

OBJECTIVE

we aimed to determine the proportion of detainees over age 60, their medical characteristics and history.

METHODS

we studied all arrestees over age 60 examined in 1 year (1st January-31 December 2012) by physicians from our Department of Forensic Medicine in the Paris, France area. Our analysis included the arrestees' perceived health status and their opinion on custody.

RESULTS

individuals over 60 accounted for 211 of 13,317 detainees (2%) and were predominantly males (177 of 211, 84%). The most frequent suspected crimes included physical assaults (135 of 345, 40%) and drunk driving (50 of 345, 14%). A total of 111 of 211 individuals (53%) reported somatic disorders. A history of psychiatric disorders was reported by 23 of 181 individuals (13%). Arrestees considered their overall health as good in 60% of cases (111 of 184). They had a good opinion on custody in 45% of cases (120 of 270). A proportion of 40% (84 of 211) were examined several times during custody and 10% were declared unfit for custody (34 of 347).

CONCLUSIONS

elderly detainees commonly have chronic health disorders; only a minority of them are unconditionally fit for detention. The continuation of detention, which affects 90% of arrestees, should imply that detention conditions are adjusted so that the specific needs of elderly individuals are taken into account.

The Alcohol-Intoxicated Person in Custody: Diagnosis, Differential Diagnosis and Management

Individuals who are intoxicated with alcohol (most commonly ethanol) will commonly be detained by police for a wide range of offenses. It is essential that custody staff are trained to recognize individuals with alcohol use disorders and comorbid health conditions and request medical assistance as required. Forensic physicians and other health care professionals should perform a comprehensive assessment to diagnose alcohol intoxication and ensure that the detainee is fit to be detained and interviewed by police. Forensic pathologists should be aware of the appropriate clinical management of alcohol-intoxicated persons in custody when involved in death in custody investigations.

Elderly arrestees in police custody cells: implementation of detention and medical decision on fitness to be detained

INTRODUCTION

Most individuals detained in police custody are male adolescents or young adults. Demeaning custody conditions, which are common in French police cells, bring to light legitimate questions about the detention of elderly people. We aimed to determine the proportion of detainees over age 60, their health characteristics and conditions of detention, and the factors included in medical decisions on fitness to be detained.

METHODS

We studied all arrestees over age 60 examined in one year (January 1st-December 31st, 2009) by forensic physicians from our department. We collected data concerning their medical histories, their experiences in police custody, and their reported assaults.

RESULTS

Individuals over 60 accounted for 180 of 15,481 detainees (1%) and were predominantly male (92%). Some arrestees were examined several times during one or more detentions such that a total of 265 medical examinations were performed. Most individuals (133 of 172, 77%) reported one or more chronic somatic disorders and 115 of 160 (72%) were currently receiving treatment for a condition. Less half of two detainees (78 of 170, 46%) expressed some complaints during examination, commonly including pain (54 of 170, 32%), and 115 of 160 arrestees (72%) received medication while in custody. Detainees were considered to be completely fit for police custody in 119 of 259 cases (46%), and 25 of 259 cases (10%) were considered to be unfit to be detained.

DISCUSSION

The harsh conditions of police custody are particularly inappropriate for elderly individuals. Guidelines for custody officers and attending physicians that take the specific health needs of older detainees into account should be implemented.

Alcohol and substance screening and brief intervention for detainees kept in police custody. A feasibility study

BACKGROUND

Screening and brief intervention programs related to addictive disorders have proven effective in a variety of environments. Both the feasibility and outcome of brief interventions performed in police custody by forensic physicians are unknown. Our objectives were to characterize addictive behaviors in detainees and to evaluate the feasibility of a brief intervention at the time of the medical examination in police custody.

METHODS

This prospective study included 1000 detainees in police custody who were examined by a physician for the assessment of fitness for detention. We used a standardized questionnaire and collected data concerning individual characteristics, addictive disorders, and reported assaults or observed injuries.

RESULTS

944 men and 56 women (94-6%) were studied. We found an addictive disorder in 708 of 1000 cases (71%), with the use of tobacco (62%), alcohol (36%), cannabis (35%), opiates (5%), and cocaine (4%) being the most common. A brief intervention was performed in 544 of these 708 cases (77%). A total of 139 of the 708 individuals (20%) expressed a willingness to change and 14 of 708 (2%) requested some information on treatment options. The main reasons why brief interventions were not performed were aggressive behaviors, drowsiness, or fanciful statements by the detainee.

CONCLUSION

Brief interventions and screening for addictive behaviors in police custody are feasible in the majority of cases. The frequent link between addictive behaviors and the suspected crimes highlights the value of such interventions, which could be incorporated into the public health mission of the physician in police custody.

Fitness for detention in police custody: a practical proposal for improving the format of medical opinion

Health issues among arrestees are a worldwide concern for which only local policies have been established. Physicians attending detainees in police custody are expected to decide whether the detainee's health status is compatible with detention in a police station and make any useful observations. A high degree of heterogeneity in the information collected by the physician and transmitted to the police has been observed. We analyzed the content and limitations of available documents and developed a model that could serve as a guide for any attending physician. The document presented here has been used in France on over 50,000 occasions since June 2010. We developed a two-page template consisting of (1) a standard medical certificate to be sent to the authority who requested the doctor's attendance and (2) a confidential medical record, not sent to the requesting authority. We evaluated perceived health by the three global health indicators of the Minimum European Health Module and used DSM IV criteria for the evaluation of addictive disorders. In the case of recent traumatic injuries, the certificate has also included the collection of data on traumatic injuries and the contexts of their occurrence. The proposed certificate achieved several goals, by protecting the interests of the person examined, in case of poor conditions of arrest or detention, protecting doctors in cases of legal proceedings, and allowing epidemiological data to be collected. The certificate may also contribute to an international awareness of medical care for detainees in police custody.

Police custody following driving under the influence of cannabis: a prospective study

Traffic offences are a common cause of detention in police custody. We hypothesized that drug intoxication while driving could correspond to specific medical conditions of the detainees. Our objective was to evaluate medical features and addictive behaviours of suspected drug drivers and to collect data regarding assaults or injuries in these individuals. We conducted a prospective study (April 2010-December 2011) of suspected drug driving arrestees, who were compared to drink drivers or persons aged over 18 detained for other reasons. Data collected concerned persons' characteristics, reported assaults, and observed injuries. A total of 205 drivers were tested positive for drugs in blood, 116 were either positive for drugs in urine or saliva and negative in blood, or negative in urine. Cannabis-only users accounted for 201 of 205 drug drivers (98%). Suspected drug driving arrestees had good overall health rating. Drug drivers were younger than controls and requested more rarely medical examination (12% vs. 44%, P<0.0001). They were rarely involved in addiction treatment (3%) and reported assaults or presented traumatic injuries less often than drink drivers and controls (8% vs. 38% and 25%, P<0.0001). Drug drivers were less often alcohol abusers than controls. Their opinion on custody was better than that of controls and they were considered unconditionally fit for detention more frequently (99% vs. 77%, P<0.0001). We conclude that arrested drug drivers were young, healthy, and infrequently reported assaults or presented traumatic injuries, which does not put them in a high risk medical condition. Medical care could include brief interventions on addictive behaviours.

Nurses leading care in custody suite environments: a qualitative study from Scotland

This paper outlines the qualitative findings of a recent multimethod study exploring the impact of nurses assuming leadership roles in delivering primary health care to detainees within police custody suites in Scotland. The full multimethod study was conducted within a framework of realistic evaluation with key findings indicating that the nurse-led model of service delivery offers positive outcomes for all key stakeholders. Findings from the qualitative component of the study showed that the quality of clinical care for detainees improved, policing concerns for detainee safety were mitigated, and forensic medical examiners were able to expand their specialist roles. Key supporting mechanisms in achieving these outcomes included generating collaborative practices, enacting clinical leadership, and providing a forensic nursing educational program to empower nurses to generate service provision and grow professional autonomy.

Can GPs working in secure environments in England re-license using the Royal College of General Practitioners revalidation proposals?

BACKGROUND

Revalidation for UK doctors is expected to be introduced from late 2012. For general practitioners (GPs), this entails collecting supporting information to be submitted and assessed in a revalidation portfolio every five years. The aim of this study was to explore the feasibility of GPs working in secure environments to collect supporting information for the Royal College of General Practitioners' (RCGP) proposed revalidation portfolio.

METHODS

We invited GPs working in secure environments in England to submit items of supporting information collected during the previous 12 months using criteria and standards required for the proposed RCGP revalidation portfolio and complete a GP issues log. Initial focus groups and initial and follow-up semi-structured face-to-face and telephone interviews were held to explore GPs' views of this process. Quantitative and qualitative data were analysed using descriptive statistics and identifying themes respectively.

RESULTS

Of the 50 GPs who consented to participate in the study, 20 submitted a portfolio. Thirty-eight GPs participated in an initial interview, nine took part in a follow-up interview and 17 completed a GP issues log. GPs reported difficulty in collecting supporting information for valid patient feedback, full-cycle clinical audits and evidence for their extended practice role(s) as sessional practitioners in the high population turnover custodial environment. Peripatetic practitioners experienced more difficulty than their institution based counterparts collating this evidence.

CONCLUSIONS

GPs working in secure environments may experience difficulties in collecting the newer types of supporting information for the proposed RCGP revalidation portfolio primarily due to their employment status within a non-medical environment and characteristics of the detainee population. Increased support from secure environment service commissioners and employers will be a prerequisite for these practitioners to enable them to re-license using the RCGP revalidation proposals.

Barriers and facilitators to a criminal justice tobacco control coordinator: an innovative approach to supporting smoking cessation among offenders

AIMS

To examine the barriers and facilitators to effective operation of a regional tobacco control coordinator working within and across criminal justice and public health, whose goal was to raise tobacco control awareness and support the development of smoking cessation treatment for offenders.

DESIGN

A reflexive, mixed-methods case study approach using in-depth interviews, project reports and observation of advisory board meetings.

SETTING

The coordinator worked with prisons, probation and police custody, where there are high levels of social disadvantage and smoking.

PARTICIPANTS

Interviews (n = 34) at different stages of project with the coordinator, project advisers and local stakeholders from criminal justice and public health.

MEASUREMENTS

Analysis of facilitators and barriers and the coordinator role from different perspectives.

FINDINGS

Readiness to develop cessation services was a critical predictor of different criminal justice settings' engagement with the coordinator role. The coordinator enhanced cessation service delivery in individual prisons where there was a requirement and infrastructure in place to provide such services. In police custody, where there was no central guidance or pre-existing requirements, efforts to establish smoking cessation on the local agenda proved ineffective. In probation settings, the coordinator documented examples of good practice and supported brief intervention training. Variability in willingness to engage limited the project's ability to create joined-up working across criminal justice settings.

CONCLUSIONS

In the English criminal justice system, the prison service appears to provide a favourable context for development of smoking cessation support and a means of accessing hard-to-reach groups. Other criminal justice settings, most specifically police custody, appear less responsive to such activity. A coordinator role can improve smoking cessation support in the prison setting, and develop local improvements in tobacco control interventions in other settings such as probation, but as configured here, does not have the capacity to effect change across the criminal justice system.

Reported assaults and observed injuries in detainees held in police custody

The deprivation of liberty in police custody can be associated with violent situations and traumatic injuries. The rare available data did not mention whether alleged assaults occurred at the time of the arrest or during custody. Our objectives were to describe the frequency of recent traumatic injuries observed in detainees at the time of medical examination and to record detainees' self-reports of received physical violence, either before being arrested, at the time of the arrest, or during custody. In 2694 consecutive detainees examined in a suburban area near Paris, we compared persons' characteristics in four groups, according to the existence of alleged assaults or the presence of recent traumatic injuries, or both. Detainees reported to be victims of physical assaults in 25% of cases (686 of 2694): 374 assaults of 686 (55%) occurred at the time of arrest and 87 of 686 (13%) during custody. The opinion of assaulted detainees on custody was worse than non-assaulted detainees. Detainees alleging assaults by the police, whatever the time of the assault, accounted for 396 cases (15%). Three quarters of detainees (547 of 686, 79%) alleging assaults had recent traumatic injuries. When we considered all detainees, medical examination showed recent traumatic injuries in 724 of 2694 (27%). Injured detainees were declared unfit for detention more frequently than non-injured non-assaulted detainees (P<0.05). These results strengthen the need and usefulness that the attending physician systematically takes note of detainees' self reports of assaults and investigates recent traumatic injuries at the time of custody.

Health screening of people in police custody--evaluation of current police screening procedures in London, UK

BACKGROUND

Previous research has highlighted excess health morbidity in offender populations. A small number of studies have described health problems within police custody settings. The efficacy of police screening procedures has not been evaluated.

METHODS

Prospective clinical interviews with custody detainees in London were conducted. Clinical findings were compared with those recorded in police health screening documentation.

RESULTS

High levels of health morbidity were observed. The sensitivity and specificity of the current screen with respect to its ability to trigger a call for a health-care professional (HCP), regardless of the reason, was 70 and 66%, respectively. Fifty-one percent of the detainees with asthma, 36% with diabetes mellitus and 40% with epilepsy were not picked up by the screen. Fewer than one-half of the detainees at risk of alcohol withdrawal syndrome had 'alcohol' documented on their screen, although 81% saw the HCP. The police screen missed heroin use in 28% and crack cocaine use in 68% of users. A HCP was called in 84 and 64% of the cases, respectively, for any reason. Two of the 12 detainees (17%) who described a head injury with serious-associated symptoms were detected; 9 had a HCP called for any reason. Whereas mental disturbance was detected in 79% of the detainees with serious mental illness, one-third of the detainees with a risk history of suicide and one-half of the detainees with suicidal ideation were not documented as such on the police screen.

CONCLUSION

Given the amounts of morbidity and the need for reliable triage, improvement in the health screening procedures used by the police is needed.

Health-care issues and health-care use among detainees in police custody

Epidemiological research on the physical health status of police detainees is scarce. The present study fills this gap by first studying the somatic reasons for consultation (n = 4396) and related prescriptions (n = 4912) as assessed by the forensic medical service during police detainment. Secondly, a health interview survey was conducted among randomly selected police detainees (n = 264) to collect information regarding their recent disease history and use of health care. Somatic health problems, medical consumption and health risk measures of the detainees were compared with those seen in the general population using general practitioner records and community health survey data. The study showed that, in police detainment, several chronic health conditions more often were the reason for consultation than in the general practice setting. In addition, the health interview survey data demonstrated that after adjustment for age and gender, the police detainees were 1.6 times more likely to suffer from one or more of the studied chronic diseases than the members from the general population. Furthermore, differences in several health risk measures, including body mass index, smoking and alcohol habits and health-care use were observed between the interviewed police detainees and the general population. These results provide insight into the variety of physical health problems of police detainees and are essential to develop optimal treatment strategies in police custody.

Medical examination of fitness for police custody in two large German towns

Worldwide, there is a high risk of medical complications or death in police custody. This risk is often increased by unclear legislation, a lack of clearly defined responsibility and medical examination standards. Any solution to these problems requires as a very basis the systematic analysis of the medical examinations that determine whether a person is fit to be detained in custody. We analysed a total of 3,674 medical records on fitness for custody, taken from two large German towns (Halle/S and Bremen). The examined individuals were predominantly males or of a younger age. The indication in the majority of cases was acute alcoholic intoxication or drug withdrawal syndromes. Traumata and internal or mental diseases were also quite frequent. For approximately 50% of all cases, fitness for custody was declared on certain conditions. Only 39.8% were found to be unconditionally fit for detention in custody. In just under 10% of the cases, the person was found unfit for custody. These cases concerned mainly persons with psychological symptoms and advanced alcohol or drug withdrawal syndromes. We were able to show that the recent introduction of new police custody regulations in Halle/S had a significant influence on the medical decision on fitness for custody. Our detailed assessment has provided us with the basis to develop solutions for the improvement of medical care in police custody. The focus lies here on the organisation and legal regulation of the medical aspects of custody but also on policing and medical work.

Health screening in police custody

BACKGROUND

There have been few previous studies on the health needs of police detainees. London's Metropolitan Police Service (MPS) uses health screening procedures which have not yet been evaluated. The objective of this study is to determine the extent of health problems and 'mental vulnerability' in detainees in police custody, and the efficacy of current health screening procedures.

METHODS

Custody records from five London Boroughs were reviewed. Prevalence data for health problems and mental vulnerability was obtained from the anonymised records of 307 detainees who were referred to the Forensic Medical Examiner (FME). Data were analysed for the identification of physical and psychiatric morbidity.

RESULTS

Injuries, epilepsy and asthma were the most common physical health problems noted. Drug and alcohol issues were also frequently encountered along with depression and self-harming behaviour and suicidal ideation. Morbidity was lower than that reported in other, interview based studies. Less than 2% of detainees were thought to require an Appropriate Adult to be present during police interview.

CONCLUSIONS

A significant amount of health morbidity is present among detainees in police custody. Our findings suggest that current police screening procedures detect only a proportion of this. Further research is warranted to evaluate the effectiveness of health screening in police custody.