Bacteriological skin and subcutaneous infections in injecting heroin users-relevance for custody

Forensic medical examiners, custody nurses and police not infrequently come into physical contact with injecting heroin users whose injection sites maybe infected. Karch evaluated published reports on bacteriological findings at infected injection sites in drug users in 1996. Studies were then 10 years out of date. Recent concern has been about unexplained deaths in injecting heroin users, partly attributed to toxins produced by Clostridium novyii, Clostridium perfringens (welchii) and Clostridium botulinum. In response to this epidemic Lambeth, Southwark and Lewisham Health Authority (London, UK) urged investigation and treatment of injection site infection in heroin users within their area; circularising police stations and general practices with an official notice. In response, I followed up and treated in general practice 35 injecting heroin users with injection site infection presenting as detainees at two South London police stations. All swabs taken had a 48 hour incubation for anaerobic bacteria. At audit, no spore forming anaerobes were found. Just under 25% had non spore forming anaerobes such as bacteroides. Just over 50% had staphylococci in the injection site infection. Just under 20% had streptococci, half of which were beta haemolytic, a possible contact risk of infection being erysipelas, cellulitis, impetigo or conjunctivitis. No comparable studies were found but a study in New York in 1984 tabulated bacteriological findings of soft tissue infections in 29 hospitalised parenteral drug users. They found similar proportions of staphylococci, far more with streptococci, hardly any with non spore forming anaerobes and one case of spore forming anaerobic clostridium perfringens.     

Healthcare issues of detainees in police custody in London,UK

Little is known about the general healthcare needs of detainees in police custody. The aims of this study were to: determine the level of general health issues, diseases and/or pathology for detainees in police custody, and to determine how well those general health issues, diseases and/or pathology are being managed. This was done by a detailed analysis of healthcare issues of a cohort of detainees and reviewing intended and prescribed medication needs with current medication availability. In August 2007, a prospective detailed, anonymised, structured questionnaire survey was undertaken of 201 detainees in police custody in London, UK. Of these 83.6% consented to participate in the study. 85.1% of subjects were male; mean age was 33.9 years; 70.8% had English as a first language; 13.7% were of no fixed abode; 70.2% were registered with a general practitioner (primary care physician); 25% were already in contact with other healthcare teams; 7.1% had previously been sectioned under the Mental Health Act 1983; 16.7% had previously intentionally self-injured; 33.9% were dependent on heroin, 33.9% on crack cocaine; 25% on alcohol, 16.6% on benzodiazepines and 63.1% on cigarettes. 56% of subjects had active medical conditions; of those with active medical conditions 74% were prescribed medication for those medical conditions; only 3/70 had their medication available. 28/70 were not taking medication regularly, and many were not taking it at all. Three subjects who had deep vein thromboses were not taking their prescribed anticoagulants and six subjects with severe mental health issues were not taking their anti-psychotic medication. Mental health issues and depression predominated, but there was a very large range of mixed diseases and pathology. Asthma, epilepsy, diabetes, deep vein thrombosis, pulmonary embolism, hepatitis, and hypertension were all represented. The study has achieved its aims and has also shown that – in part because of the chaotic lifestyle of many detainees – appropriate care was not being rendered, thereby, putting both detainee, and potentially others coming into contact with them, at risk.     

The extent of injecting and syringe sharing in prison reported by Edinburgh drug clinic attenders

68 outpatient attenders at Edinburgh's Community Drug Problem Service who reported a history of drug injecting and who had spent 1 week or more in prison between March 1987-March 1990 were interviewed about drug injecting behaviour and syringe sharing before and during each prison episode they reported. One-third of those injecting prior to prison continued to do so in prison, most doing so twice weekly or more. 80% of prison injectors shared syringes in prison. No subjects commenced their injecting career in prison, and being imprisoned did not cause past injectors who had stopped to resume injecting in custody. Being imprisoned tended to cause non-sharing injectors to resume sharing in prison. Prison injectors tended to have started both their oral and their injecting drug use careers at an earlier age, and to have been sharing syringes in the community prior to custody. Half of prison sharers used unofficially acquired bleach or disinfectant to sterilise injecting equipment. Continuing involvement with the courts and thus risk of reimprisonment was common. The findings support the case for harm reduction policies in Scottish prisons, and diversion from custody and into treatment for this high risk group.     

Provision of forensic medical services to police custody suites in England and Wales: Current practice

IntroductionPolice services within England and Wales are required under the Police and Criminal Evidence Act 1984 to ensure appropriate healthcare to those detained in police custody (forensic medical services). Traditionally doctors have been used by police services to provide an appropriate level of care. Changes within the Act allowed other healthcare professionals (nurses and paramedics and emergency care practitioners) to be included in the provision of such services. The aim of this appears at least in part to have been to reduce the costs of providing such a service. In recent years police services within England and Wales have been outsourced to assorted commercial providers. There are now several different modes of delivery of forensic medical services, which are determined locally by separate police services.AimsThis study aimed (a) to determine the different modes of delivery of forensic medical services in England and Wales; (b) to determine the healthcare workload caused by Police and Criminal Evidence Act 1984 Codes of Practice; (c) to determine the relative costs of different service models and (d) to determine availability of such information from the police services.MethodsThe study was undertaken in two parts – (a) a telephone survey of all police services, and (b) an application to each police service utilising the Freedom of Information Act 2000.ResultsAll police services (n = 43) in England and Wales were contacted. Of the 41forces that furnished detailed information; 13/41 had a doctor only service; 20/41 had a doctor/nurse service; 6/41 had a doctor/nurse/paramedic service; 1/41 had a doctor/emergency care practitioner service (who may be nurses or paramedic); 1/41 had a doctor/paramedic service. 23/43 services were outsourced to private commercial providers. Mean cost per patient contact (in 17/43 services which supplied data) was GBP 97.25. The cheapest cost per patient contact was the Metropolitan Police Service – a doctor only service (GBP 56.4), the highest Lincolnshire – a doctor only service (GBP 151.1). Mean cost for a doctor only service was GBP 97.1; for a doctor/nurse service – GBP 91.56 and for a doctor/nurse/paramedic service – GBP 115.76. There was no significant difference in costs per patient contact between a doctor only versus mixed HCP delivery of service. Relative costs and 95% confidence intervals expressed as a percentage show that a doctor only model was on average 3.4% lower than a mixed HCP provision, and that a non-outsourced service was on average 9.9% less than an outsourced service. No outsourced service in this study uses a doctor only model.ConclusionsThe study shows that there was a complete lack of consistency in the recording and availability of information regarding forensic medical services for police services in England and Wales. The information that was obtained suggested that usage of such services varied greatly between police services and that costs of forensic medical services appear to be increased by the use of mixed healthcare professional service delivery and by using external commercial providers.     

Medical,social, and law characteristics of intoxicant's users medically examined in police custody

IntroductionThere are no studies on medically examined persons in custody which specifically focus on identifying dependence profiles among users of intoxicants. Nonetheless, the characterisation of dependence profiles for intoxicants such as alcohol, cannabis, cocaine, heroin, amphetamines and their by-products is a medical necessity in this setting.Materials and methodsA prospective, monocentric, open-ended study conducted by structured questionnaire was carried out on detainees who admitted to having taken an intoxicant/s (tobacco, alcohol, drugs or illegal substances). Social, legal and medical data were collected. The aim of the study was to explore characteristics of these persons in police custody.Results817 questionnaires were examined. More than one-third have a dependence on at least one substance. 37.7% were dependant of tobacco, 86.5% of drinkers, 24.7% of cannabis users. Of these, 90.1% were from men with a mean age of 29.4 years, 40% from individuals living alone, 25.7% from persons with no financial means and 19.6% from homeless persons. 10% were believed to be suffering from mental illness, 7.2% were thought to be asthmatic, 3% to have a chronic infection, and 2.9% to have epilepsy. 36.2% reportedly received treatment, 37.5% of which included benzodiazepine and 20.3% opiate substitution therapy. Incidence of psychological and psychiatric disorders is close to 10% of intoxicant detainees.DiscussionIn this study, some of the stated pathologies occur in ratios similar to those in other published results. But, there is a high, and probably underestimated, prevalence of psychological and psychiatric disorders in this population of detainees reporting exposure to intoxicant or illegal substances.     

Concealment of drugs by police detainees: lessons learned from adverse incidents and from 'routine' clinical practice

This is a collaborative piece of work undertaken between the PCA and a Principal FME. The study is based on 16 cases of internal drug concealment drawn from 43 drug-related deaths in custody in England and Wales between 1997 and 2002. These data are supplemented by three case studies from a county force involving non-fatal drug concealment to illustrate practical custody issues. The majority of the 16 deaths were white (n = 12) and male (n = 13) with a mean age of 34 years. In half of the cases, the deceased was known or believed to have concealed drugs orally at the point of initial contact with police. In 4/16 cases, the individual first showed signs of medical distress in a public place, a further 4 collapsed on arrival at the police station and two more detainees were subsequently found collapsed in their cell. Drug toxicity was the most common cause of death (10/16). In 5 cases death was caused by airway obstruction by swallowed packages. Both cocaine (14/16) and cannabis (8/16) traces were found in post-mortem samples. The report emphasises the need for a safety first approach.     

Concentrations of Δ9-tetrahydrocannabinol,cocaine and 6-monoacetylmorphine in hair of drug abusers

Hair samples taken from 850 individuals with presumed drug abuse were tested simultaneously forΔ⁹tetrahydrocannabinol (THC), cocaine, heroin, the primary heroin metabolite 6-monoacetylmorphine (6-MAM) and morphine. The drugs were extracted with methanol under sonication. Compared to other extraction procedures this solvent extraction technique provides high extraction yields and less experimental effort. The analyses were carried out using gas chromatography - mass spectrometry (GCMS) in selected ion monitoring (SIM) mode. This procedure allows the simultaneous detection of amphetamine, methylenedioxyamphetamine (MDA), methylenedioxymetbamphetamine (MDMA) and methylenedioxyethylamphetamine (MDE). THC was found in 104 (12.2%), cocaine in 230 (27%) and 6-MAM in 141 (16.6%) samples. In addition to 6-MAM, morphine was detected in 87 (10.2%) and heroin in 38 samples (4.5%). The concentrations found were in a range 0.009-16.7 ng/mg for THC, 0.037-129.68 ng/mg for cocaine, 0.028-79.82 ng/mg for 6-MAM, 0.045-53.14 ng/mg for heroin and 0.011-7.800 ng/mg for morphine. The statistical distribution of the drug concentrations compared with the self-reported consumption behaviour of the users may possibly lead to a better understanding of the relationship between drug dosage and corresponding concentrations in hair.     

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

BackgroundThere 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.MethodsCustody 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.ResultsInjuries, 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.ConclusionsA 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.     

Illicit drug profiling: the Australian experience – revisited

In Australia drug profiling had its formal beginnings during the early 2000s. Initially, this involved the development of a heroin signature program by the Australian Federal Police and the National Measurement Institute, which was then expanded to include cocaine, and by 2007 both programs had reached a mature state. From then, the focus switched to high volume synthetic drugs such as methylamphetamine. This paper describes the expansion of the Australian Illicit Drug Intelligence Program (AIDIP) to include a range of chemical signatures aimed at investigating the clandestine manufacturing methods and precursor chemicals used for synthetic drugs such as methylamphetamine. It also describes the commencement of the Enhanced National Intelligence Picture Illicit Drugs (ENIPID), which was designed to monitor domestic drug seizures in the Australian States and Territories with the goal of establishing links to drug trafficking into Australia. Examples of links between domestic, Border and international seizures are explored. Finally, the changing nature of drug trafficking into Australia during the last decade is considered in the context of how forensic chemistry laboratories need to be adaptable and willing to evolve as the threat from illicit drugs evolves.     

Todesfälle im Gewahrsam

A total of 86 autopsy cases of death in imprisonment have been analyzed of which 66 occurred in prison and 20 during parole. The deaths in prison were mainly due to suicide or drugs, while those on parole occurred because of intoxication with more than one substance. Means to decrease drug-related mortality are discussed. Furthermore, we report four cases of death in police custody.     

A profile of deaths in custody in Victoria, 1991-96

In Victoria, all deaths in custody are investigated and a coronial inquest is held. The findings are entered into a data base held at the Victorian Institute of Forensic Medicine. Utilizing this data base, all listed cases of deaths in custody during the 6-year period, January 1991-December 1996, were reviewed. The deceased's age, sex, cause and mechanism of death and the custodial service under which they were held at the time of death were correlated. During the 6-year period, there was a total of 96 deaths (90 male, six female) ranging in age from 15-77 years. Of all the cases, 45 occurred whilst in police custody, 30 under corrective services and 21 involved non-custodial corrections. There were 31 accidental deaths, 29 suicides, 17 natural deaths, and 18 police shootings. Excluding police shootings, 42 deaths involved the presence of drugs or alcohol, either as a direct cause of death or as a contributory factor. Drug toxicity alone was implicated in 28 deaths. Deaths from unnatural causes remains the major cause of death of persons in custody. An awareness of these causes must assist in developing mechanisms to further reduce fatalities in this setting.     

Methicillin resistant Staphylococcus aureus (MRSA) in an injecting heroin user: implications for hygiene in police station custody suites

A 32 year old male was seen as a detainee, with multiple injection site abscesses. He was followed up in general practice, subsequent to debridement of injection site abscesses on both deltoid regions. Follow up swabs grew Methicillin resistant Staphylococcus aureus (MRSA) from both debridement areas. This case report confirms that MRSA can occur in heroin injection site ulcers in the UK. Such a finding in San Francisco is not unusual. Special care should be taken of post debridement ulcers found in a heroin injecting patient/detainee. MRSA could contaminate the custody area and all police authorities need to have an MRSA policy. This case report has implications for custody, suites in police stations, examination rooms and cell hygiene.     

Health needs of detainees in police custody in England and Wales. Literature review

The aim of this systematic is to review and analyse the literature concerned with the health needs of detainees in police custody in England and Wales.The healthcare of detainees in police custody is regulated by the England and Wales Police and Criminal Evidence Act 1984. The Faculty of Forensic and Legal Medicine of the Royal College of Physicians also sets quality standards for the provision of custodial healthcare. The provision of healthcare in custody presents a number of challenges including the patient group, the setting and the overlap between the legal and medical concerns that are addressed by the medical team. Currently, care to the detainees in custody is delivered by a mixture of private organisations, police-led forensic medical services and the NHS.A search of the PUBMED, EMBASE and PsycINFO databases undertaken using the search terms: (police custody) OR (detainees) OR (police detainees) yielded 830 publications. All of the titles were screened to identify potentially relevant publications concerned with the health needs of detainees in police custodies in England and Wales. There were no design specific criteria set for inclusion of the studies in this literature review. 77 articles were initially identified as relevant and obtained in full. After further analysis 28 publications were included in this literature review.A total sample of over 12,000 detainees was examined in this literature review. Approximately 20% of detainees seen by health care teams suffer from psychiatric conditions. On average, 50% of patients claim that they have problems with drugs and alcohol. Physical health conditions are also highly prevalent with up to 74% of detainees requiring regular medication. Forensic medical issues included the management of detainees who were restrained using handcuffs, irritant sprays and TASER. Detainees who are suspected of internal drug concealment also require intensive medical input. Injury documentation in custody is often requested for both the police officer and detainees.Current literature indicates that mental health problems including substance misuse and physical conditions are highly prevalent among the custody population and require both emergency and routine care. The current quality of the health-care services has been discussed and the need for improvement has been indicated by a number of agencies. Recent attempts have been made to incorporate the custodial services into the general structure of the NHS, aiming for more robust governance and standardization of services. Implementation of a routine health promotion service in custody has also been discussed which can be integrated into the general health care provision during detention.     

Interpretation of lesions of the cardiac conduction system in cocaine-related fatalities

This study examines cases of chronic drug users who died suddenly after drug administration. Victims were young subjects, aged from 19 to 35 from Switzerland and known to the police as long-term drug users. The circumstances of death suggested the occurrence of a sudden, unexpected death. Some victims were undergoing methadone treatment. In each case, a forensic autopsy and toxicological analyses were performed at the Institute of Forensic Medicine in Lausanne in Switzerland between 2002 and 2004, including hair analysis as a means to establish chronic drug use in general, and cocaine use in particular. The conduction system was examined histologically and cases showing potentially lethal changes were chosen for this report. The most frequent lesions found were severe thickening of the atrioventricular node artery, intranodal and perinodal fibrosis, and microscopic foci of chronic inflammatory infiltration. The authors conclude that pathological lesions in the conduction tissue may play a role in the occurrence of death attributed to intoxication consecutive to cocaine ingestion.     

The mental health needs of people with a learning disability detained in police custody

Few research studies examine the prevalence or mental health needs of people with a Learning Disability (LD) detained in police custody. This paper describes the population of detainees with an LD who presented to an inner city inter-agency police liaison service during a three-year period. Two forensically trained Community Mental Health Nurses (CMHNs) screened all custody record forms (n=9014) for evidence of a mental health problem or LD. The CMHNs interviewed positively screened detainees (n=1089) using a battery of measures designed to assess mental health status, risk-related behaviour and alcohol or drug abuse. Almost one-in-ten of those interviewed (95/1089) were judged to have a possible or definite LD. Fifty-two per cent were cases on the General Health Questionnaire (GHQ) whilst 61% attained 'above threshold' Brief Psychiatric Rating Scale (BPRS) scores. The majority (63%) had a history of causing harm to others while 56 per cent had a history of self-harm. More than half (56%) regularly consumed harmful levels of alcohol while one-in-four (27%) reported abusing drugs. Higher than expected numbers of detainees have a learning disability and most have complex mental health needs. A police liaison service offers a way of identifying people with LD and connecting them with appropriate health and social care agencies.     

Frequency of traumatic lesions alleged by victims of assault during police custody

A retrospective study was undertaken to determine the frequency of traumatic lesions found in individuals alleging police brutality during official custody in the département of Hauts-de-Seine, located in the west suburbs of Paris. All medical certificates relating to the examination of 11,653 individuals detained during the year 2004 were analysed. From this population, there were 119 cases where victimized individuals alleged police assault and 245 revealed aggressive police manhandling, as indicated by traces of tight handcuffs. Among the individuals alleging police violence, most of them showed recent traumatic lesions (n=91). The majority of lesions were superficial contusions frequently located in the cervico-cephalic area. All traumatic lesions were compatible with the allegations of police assault. Neurological complications secondary to the application of handcuffs were encountered in less than 2% of the cases. Although no death was recorded in police custody during the period of the study, approximately 5% of the population that had encountered some form of police violence was found to require emergency hospitalization.     

Surgical and non-surgical treatment of non-traumatic gallbladder perforation

Objective

Our aim was to present a single-center experience in the management of gallbladder perforation (GBP).