Assessment and management of individuals under the influence of alcohol in police custody

Individuals taken into police custody are commonly under the influence of alcohol. Some of these individuals are dependent on alcohol and suffer from withdrawal symptoms. Morbidity and mortality in this group is high, and deaths have been recorded in police custody. There are no specific guidelines on the assessment and management of individuals under the influence of alcohol taken into police custody. This article outlines the clinical features, assessment, investigations and management of these individuals based on a review of the literature.     

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.     

The medical management in police custody of alcohol dependent detained persons

The author devised a simple postal questionnaire which was sent to all of the UK members of the Association of Police Surgeons, requesting information about their management in police custody of alcohol dependent persons detained by the police. The questionnaire and the results are presented. The results are analysed. The detention by the police of alcohol dependent patients is dangerous as these patients are at risk of sudden death. Some of the relevant literature is considered and then a suggested management scheme for such a situation is proposed.     

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.     

The working practices of the police in relation to mentally disordered offenders and diversion services

A research study was undertaken to examine the working practices of four bridewells in Hampshire in relation to mentally disordered offenders (MDOs) and diversion services. A consecutive sample of individuals detained in cells and not identified by the police as having a mental disorder were screened for the presence of mental disorder and their suitability for diversion. Custody and detention staff were observed and interviewed to elicit their views and working practices in relation to MDOs. The findings revealed that in bridewells with diversion schemes an average of about 7% of detained individuals had mental disorders who were suitable for diversion but were not detected by the police. In the bridewell without a diversion scheme the figure was 14%. Conversely, many individuals without a formal mental disorder were inappropriately referred to diversion schemes. The effectiveness of screening processes by custody staff was variable. Facilities in the bridewells were not suitable for containing disturbed individuals. Delays in obtaining mental health assessments caused considerable concern for police officers and prolonged the discomfort of vulnerable individuals. Further preparation and training of custody staff is needed to improve screening procedures. Reception and detention facilities for mentally disordered individuals should be reviewed and response times for approved social workers (ASWs) and psychiatrists would benefit from improvement.     

'Alcohol intoxication' or 'drunkenness': is there a difference?

The terms 'alcohol intoxication' and 'drunkenness' have hitherto been used interchangeably. A distinction between these terms is justified. Anthropological research suggests that the behaviour displayed by people who have consumed alcohol has more to do with culturally-determined expectations than with the properties of alcohol. Subjects who believe they have consumed alcohol when they have not behave more aggressively than those who believe that they have not consumed alcohol. There are significant false-positive and false-negative rates when doctors use clinical signs to judge whether or not a patient is intoxicated. People who die in police custody after arrest for offences of drunkenness include a proportion who have a negligible quantity of alcohol in the body and whose cause of death is unrelated to alcohol. It is proposed: (1) that the term 'alcohol intoxication' should refer to a state in which alcohol is present in the body; (2) its diagnosis should be based on toxicological evidence for the presence of alcohol in body fluids or tissues; and (3) the term 'drunkenness' should be used to describe behaviour displayed by people who have consumed, believe that they have consumed, or want others to believe that they have consumed, alcohol. Some clinical and legal implications of this distinction are discussed.     

Detainees in police custody in the Paris,France area: medical data and high-risk situations (a prospective study over 1 year)

Background and objective

The annual number of detainees held in police custody in France is approximately 700,000. Medical data regarding arrestees are scarce across countries. We present the medical characteristics of detainees kept in police custody, including addictive behaviours and high-risk medical situations.

Methods

We conducted a prospective study over 1 year in a suburban area near Paris.

Results

A total of 19,098 medical examinations were performed on 13,317 individuals. The examinations mainly concerned male subjects (18,116 of 19,098, 95 %). Median age was 24 years (range 13–83). Medical examination was requested by the detainee in 6,638 of 16,801 cases (40 %). Assaults were reported in 4,052 of 17,312 cases (23 %) and occurred at the time of arrest in most cases (2,243, 13 %). A total of 2,394 of 13,317 detainees (18 %) had at least one chronic somatic disorder including asthma (603, 5 %), diabetes (263, 2 %) and arterial hypertension (205, 2 %). A history of psychiatric disorder was reported by 6 % of individuals (674 of 11,787). Regular alcohol drinking was reported by 58 % of detainees. Illicit drug use mainly involved cannabis (4,021 cases, 30 %). In 14,661 of 19,098 cases (77 %), detainees were considered to be unconditionally fit for detention in custody, and 274 detainees (1 %) were declared unfit to be detained.

Conclusion

The present study showed a high frequency of alcohol or substance use and reported assaults or traumatic lesions in arrestees. Attending physicians should pay particular attention to addictive behaviours and traumatic injuries in arrestees, both for immediate care and for prevention.     

Near miss incidents in police custody suites in London in 2003: a feasibility study

INTRODUCTION: Potentially preventable deaths in police custody include those which involve illicit drugs, alcohol and deliberate self-harm. Near miss incidents (NMI) that did not result in death have a crucial role in understanding risk factors in custody. Such research has not previously been undertaken. A program of research has been developed to study NMI, in order to better identify those at risk in police custody. For the purposes of this research, NMI have been defined as 'an unplanned and unforeseeable or unforeseen event that could have resulted, but did not result, in human death or may have resulted in injury or other adverse outcomes'. It was intended that the definition although broad, would not include simple accidents (e.g. slipping on urine in a cell) or trivial injury. AIMS AND METHODS: The two aims of the study are (a) to determine whether it is realistic to attempt to assess NMI with the intention of identifying information of use in enhancing detainee care and (b) to assess how frequently NMIs occur and whether there are specific patterns. Pilot interviews were conducted with three forensic physicians practising in London, UK to create a structured questionnaire for all forensic physicians working in London. The questionnaire provided the basis of a retrospective recall survey of all forensic physicians working in London as Forensic Medical Examiners. The questionnaire was designed to assess the numbers of NMI, patterns in occurrence and relevant learning points within the previous 6 months. A covering letter, background questionnaire (exploring the background of the medical practitioner), copies of the survey, and reply paid envelopes were sent to each Forensic Medical Examiner (n=134) in London, contracted to provide forensic medical services for the Metropolitan Police Service. Data about all incidents were anonymized. RESULTS: Ninety six (73%) Forensic Medical Examiners responded. Of these 18% were Principal grade, the remainder were Senior (24%), Standard (35%) and Assistant (23%). Thirty eight NMI were reported by 27 Forensic Medical Examiners (of all levels). The initial reason for police contact was recorded as alcohol (n=8), theft and robbery (n=7), warrants (n=4), violence (n=3), traffic violations (n=2) and single cases of drugs, murder and immigration offences. Of the main perceived cause of each NMI, illicit drugs were involved in 12/38, alcohol in 17/38, deliberate self-harm in 11/38, issues concerning searches, checks or rousing in 8/38, failure of inter-agency communications in 5/38, and possible resource issues in 4/38. In a number of cases more than one factor was involved. CONCLUSIONS: The information established about NMI is broadly consistent with documented patterns of deaths in police custody in England and Wales which supports the validity of the data. The next stage of this research will be a prospective six month study in which NMI will be analysed in order to learn lessons which may be utilised to attempt to prevent potentially avoidable deaths 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 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.     

Police custody deaths in Maryland, USA: an examination of 45 cases

Previous published research suggests there are a diverse, yet relatively consistent, set of factors present in sudden, unexpected, and initially inexplicable deaths in police custody. This retrospective analysis examines police custodial deaths in Maryland, USA. Police custody death is operationalized to include deaths which occurred suddenly and unexpectedly during police/citizen encounters. Only deaths for which the cause was initially undeterminable are included. Suicidal hanging, police shootings and fatal pursuits are not included. Review of the records at Maryland’s Office of the Chief Medical Examiner indicates that 45 persons died suddenly and unexpectedly in the custody of the police, between 1990 and 2004. Commensurate with existing research, our analysis identifies multiple factors generally present in this type of police custody death. Although individual-specific, these factors include a relatively static constellation of behavioral (e.g., erratic and/or violent behavior, and physical struggle) and physical (e.g., stimulant abuse, natural disease, and obesity) dimensions. While the presence of these factors has been well-documented, their empirical significance, interactions and causal sequence have yet to be established. To increase the methodological rigor of subsequent research, we have developed a comprehensive, national custody death database by which multivariate models may be analyzed.     

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.     

The clinical management of substance misusers in police custody -- a survey of current practice

Large numbers of substance misusers are seen in police custody. Their management remains a significant part of a forensic physician's workload. Substance misuse, including alcohol, is a factor in a substantial number of deaths in custody. Guidelines have been produced on the acceptable minimum standards for assessment and treatment. The aims of this study were to determine the current attitudes and practice of forensic physicians to see whether there had been any change in practice since their publication. The results suggest that the majority of respondents had read the guidelines. However, there were still considerable variations in practice and circumstances where the minimum standards were not being achieved. Whilst 90% of respondents felt confident in dealing with substance misusers, many commented that further information on specific drugs and further training on management of substance misusers would be beneficial.     

What happens afterwards? A follow-up study of those diverted from custody to hospital in the first 2.5 years of a metropolitan diversion scheme

BACKGROUND: Court-based psychiatric services aim to identify mentally disordered defendants who require help from Mental Health Services, and attempt to arrange the necessary diversion into health care. This study followed individuals through their hospital stay to assess whether the psychiatric facility to which the individual was transferred was able to manage them, assessed whether the individual benefited from diversion into hospital, and examined how and when the individuals were discharged into the community. METHOD: All those diverted from custody to hospital in the first 2.5 years of a metropolitan diversion scheme were followed through their hospital stay for at least 18 months. RESULTS: Fifty five people were diverted into hospital, from a total of 180 referrals to the court diversion scheme, In excess of 80 per cent were suffering from some form of psychotic disorder. This group had committed relatively serious offences. If appropriately assessed, and appropriate hospital placements are arranged, successful outcome can be achieved for the majority of people diverted from custody to hospital, in terms of improved mental states and a planned discharge. CONCLUSIONS: The services provided by general psychiatric services are able to meet the needs of this group.     

Asthma management in police study

Asthma is a common condition and, therefore, may be seen by the clinical forensic physician and police in widely different circumstances ranging from the autopsy room to roadside breath alcohol testing. This paper concentrates on the assessment and treatment of asthmatics detained in custody and does not refer to the Road Traffic Act provisions. A careful history and objective recording of simple severity markers and peak expiratory flow rate should identify patients who may require hospitalization or urgent treatment. Asthma mortality may be reduced by better understanding of the disease and its treatment and by greater use of prophylactic rather than reliance on relief therapy for bronchospasm.     

The comparison of disposal attitudes towards forensic psychiatric patients among police officers,psychiatrists and community members in China

ObjectiveTo understand disposal attitudes towards forensic psychiatric patients among police officers, psychiatrists and community members in China.Method118 community members, 121 psychiatrists and 105 police officers completed a questionnaire regarding disposal attitudes towards forensic psychiatric patients.ResultSurveyed respondents (87.4%) believed patients with mental disorders experienced discrimination, and 97.4% were in favor of providing livelihood security for them. Police officers (89.5%) agreed that patients with mental illness were more violent than the general population, which was significantly higher than 74.4% of psychiatrists (X² = 14.29, P = 0.000). Among three groups, the most preferred disposal option for those found not guilty by reason of insanity (NGRI) was to treat them in the custody of a forensic psychiatric hospital, such as an Ankang Hospital (86.9%). The respondents agreed (96.8%) that an independent review board should be established for disposing decisions for forensic psychiatric patients. The percentage who agreed that police officers, prosecutors, and judges should be included in the review board was significantly higher among police officers than among community members (x² = 6.60, P = 0.01; x² = 9.74, P = 0.002; x² = 7.38, P = 0.007). When asked, “who has the legal right to determine whether offenders with mental disorders should bear criminal responsibility”, forensic psychiatrists and judges were the top two responders (79.5% and 63.4%, respectively).ConclusionThis study suggested that the majority of those surveyed, especially police officers, held that patients with mental illness were violent and should receive violence risk assessments. Although psychiatrists paid more attention to the rights of patients, they also lacked legal knowledge, similar to community members and police officers. Therefore, it is necessary to inform the public regarding mental health, and to provide legal knowledge.     

Who takes alcohol prior to suicide?

Alcohol abuse is strongly associated with suicide. Alcoholics are at a high risk of suicide, and studies of case series of suicide show that alcoholics account for between 20% and 40% of all suicides. What is less clear is the role of alcohol in the events leading up to the suicide. This study reviews the characteristics of individuals who consumed alcohol prior to suicide. All cases of suicide assessed by the Department of Forensic Medicine, Dundee University between 1988 and 1995 were reviewed. Data were obtained on blood-alcohol levels of 349 cases, together with the method and circumstances of the suicide, demographic variables and reports of past psychiatric history. Forty-five per cent of suicide cases had consumed alcohol and 19% were drunk (BAC > 150 mg/dl) at the time of the suicide. Consumption of alcohol was not associated with a particular method of suicide, nor with social factors such as employment status, marital status or social class. However, alcohol use was more common among those with no previous psychiatric history. This study confirms that alcohol consumption is a common precursor to suicide. It suggests that alcohol may play a more important role in the events leading to suicide amongst individuals with no previous psychiatric history.     

Characteristics of drug misusers in custody and their perceptions of medical care

Substance misuse detainees in custody are a common problem for forensic physicians. Studies have shown that forensic physicians have negative attitudes towards misusers in custody. Inconsistent information may be given by the detainee to acquire some perceived secondary gain. Therefore, it is difficult for the examining physician to gain an impartial insight into the detainees' expectations of their medical management. This study was undertaken to explore the detainees' expectations of their medical management by administration of a questionnaire using drug referral workers who are independent of the police and the forensic physician. The practical difficulties of producing such a survey and the results are discussed.