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.     

The Cinderella section: room for improvement in the documentation and implementation of Section 136 of the Mental Health Act 1983

A questionnaire sent to all 43 police forces in England and Wales confirmed that there was a lack of understanding of the documentation issued by central government detailing section 136 of the Mental Health Act 1983. A survey of forensic physicians in England and Wales reveal that doctors providing medical care in police stations had insufficient knowledge of the Act.     

A tiered healthcare system for persons in police custody--the use of a forensic nursing service

In February 1992 the healthcare programme for persons held in police custody within the Melbourne metropolitan area was restructured. This was undertaken as a joint exercise between Police, the Health Department and the Office of Corrections as a response to the need to develop an efficient and cost effective healthcare delivery system. A tiered medical response was instituted, utilising a forensic nurse for the primary medical contact with forensic physicians providing medical consultation and support as necessary. Criteria were developed regarding the delineation of duties appropriate for the forensic nurse and for the forensic physician. The nurses were provided with transport, communication and basic medical supplies enabling a flexible response to requests for medical attention and for the nurse to perform triage, a basic medical assessment and administer appropriate treatment. Over the 15-month period since inception over 3000 consultations have been performed by the forensic nurses. The service has been commended by police, doctors working in the prison system, forensic physicians and community groups. A comprehensive review has demonstrated the efficiency and reliability of such a service. Costs in providing the service have not increased. We conclude that a forensic nursing service is of considerable benefit in complementing a range of services provided by forensic medical officers in a metropolitan setting.     

A clean bill of health? The efficacy of an NHS commissioned outsourced police custody healthcare service

Police custody healthcare services for detainees in the UK are most commonly outsourced to independent healthcare providers who employ custody nurses and forensic physicians to deliver forensic healthcare services. A pilot was introduced in 2008 by the Department of Health to explore the efficacy of commissioning custody healthcare via the NHS, in the wake of the 2005–2006 shift of prison healthcare to the NHS. The objective was to improve quality and accountability through NHS commissioning and the introduction of NHS governance to the management and delivery of custody healthcare. This article discusses key themes that arose from the project evaluation, which focused on the commissioning relationship between the police, the NHS commissioner and the private healthcare provider. The evaluation observed an evolving relationship between the police, the local NHS and the front-line nurses, which was complicated by the quite distinctive professional values and ideologies operating, with their contrasting organisational imperatives and discordant values and principles. A key challenge for commissioners is to develop synergy between operational and strategically located stakeholders so that they can work effectively towards common goals. Government policy appears to remain focused on creating safe, supportive and humane custody environments that balance criminal justice and health imperatives and support the rights and needs of detainees, victims, professionals and the public. This remains an ambitious agenda and presents a major challenge for new criminal justice health partnerships.     

Taking samples under the Police and Criminal Evidence Act 1984

This article reviews the changes that have been made in England and Wales by Part IV of the Criminal Justice and Public Order Act 1994 to the powers conferred on the police by the Police and Criminal Evidence Act 1984 to take and to retain for statistical purposes intimate and non-intimate samples from suspects. These changes follow recommendations made by the Royal Commission on Criminal Justice which reported in 1993. They signal a significant increase both in police powers and in the future work of the police surgeon.     

‘Stop: think forensic’ – developing a framework for contamination minimization for police and forensic staff

ABSTRACT

The Victoria Police Forensic Services Department (VPFSD) has developed a single framework for both forensic science staff and operational police to cover procedures and training in Contamination Minimization.     

Forensic medicine services in Uganda--present and future

Forensic medicine services (medico-legal services) as it is provided today in Uganda is discussed with special reference to forensic pathology and also to future plans for improvement to ensure quality service. Forensic medicine services are divided into clinical forensic medicine and forensic pathology. In Uganda, these services are rendered partly by pathologists attached to University, by pathologists and medical officers employed by police and by medical officers attached to hospitals. In Uganda, all types of unnatural deaths are reported to nearest police station and appointed investigating police officer(s) will take necessary action to have a medico-legal postmortem done as soon as possible. Currently there is no qualified forensic pathologist in Uganda. Suggestions are made with regard to the enactment of a Forensic Medicine Services Act by the Department of Health, the creation of a forensic medicine unit with, under the administrative umbrella of pathology department, in medical schools and imparting of forensic medicine training to anatomical pathologists to act as a qualified, specialist forensic pathologists.     

Fingerprint evidence in England and Wales--the revised standard

Evidence of personal identity, often based solely on the comparison of a single finger impression, or fragment of an impression, has been accepted by courts of law at all levels in England and Wales since 1901, when the fingerprint system of identification was first adopted by police forces. Fingerprint identification is used by police forces world-wide, not only for the identification of latent fingermarks left at crime scenes, but also as the basis for ensuring accuracy in the criminal record system. For more than a century fingerprint evidence has been shown without doubt to be the best form of personal identification yet devised and millions of comparisons and subsequent identifications have been effected world-wide without any flaw in the system having been detected. From 1953-2001 it was the usual practice in England and Wales for the police to proffer fingerprint evidence showing 16 common matching characteristics, or features in agreement, between the two impressions being compared. In 1996 the Association of Chief Police Officers (ACPO) commissioned a review of the existing methods of presenting fingerprint evidence before the courts and on 11 June 2001 a new standard of fingerprint evidence was adopted by the police forces of England and Wales. This paper describes how the new standard was developed and implemented and why it was considered necessary to move away from the existing 16-point standard.     

The vulnerable adult in police custody: lessons learned from the case of R v Paul James Aspinall

This case review highlights some of the problems that vulnerable adults, especially those with a mental disorder as defined in section 1 (2) of the Mental Health Act 1983, face in police custody. These service users already experience some form of discrimination within the wider society in terms of access to community services. The role of the appropriate adult in providing support to the person in custody is fundamental, as enshrined in the Police and Criminal Evidence Act 1984 Code of Practice. It is one of the important safeguards of the legislation often referred to as a 'gateway safeguard' because it leads to other safeguards. The roles and functions of the custody officer are reviewed.     

Trends in less-lethal use of force techniques by police services within England and Wales: 2007–2011

The aim of this study was to determine the incidence of, and any changes in, usage patterns of the less-lethal forms of Use of Force (UoF) modalities—incapacitant spray, impact rounds, and Taser^R—between 2007 and 2011 by English and Welsh police services. Additional information regarding the deployment and discharge of firearms was also sought. Two thousand Freedom of Information Act applications were made to 50 police services in England and Wales and related jurisdictions requesting the provision of: (a) the total number of deployments of incapacitant sprays, Taser^R, impact (baton) rounds, and armed response units (ARU); (b) the numbers and types of any resulting medical complications; and (c) the details of any local policies requiring assessment by a healthcare professional following a deployment. Responses were received from 47 police services, with only 10 of these supplying complete data. The remainder supplied incomplete data or refused to supply any data under s12 of the Freedom of Information Act (time and cost restrictions). From 2007 to 2011, the use of incapacitant sprays, Taser, and firearms have increased (incapacitant sprays deployed: 3496, 3976, 6911, 6679, 6853; Taser deployed: 499, 2659, 4560, 6943, 7203; Taser discharged: 15, 85, 161, 338, 461; firearms: 0, 7, 4, 19, 32). Baton rounds and ARU use showed greater variability over the same time period (baton rounds: 1007, 1327, 1123, 1382, 1278; ARUs: 11688, 13652, 13166, 13959, 12090). Only two services could provide details of medical consequences from use of incapacitant sprays, Taser, and baton rounds. No service could provide details of any related medical complications following use of firearms. Data collection and release are variable and inconsistent throughout English and Welsh police services and thus caution is needed in determining trends of UoF techniques. Deaths or injuries inflicted using UoF techniques result in much public scrutiny and the low level of data recorded in these cases is of concern. Common systems for recording use and adverse outcomes of UoF techniques are needed to inform the public and others who have concerns about such techniques.     

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.     

Facilities for complainants of sexual assault throughout the United Kingdom

BACKGROUND: A sexual assault referral centre (SARC) is a model of service established to address the forensic and therapeutic needs arising following sexual assault. As yet, only a minority of urban areas in England are served by one, the rest of the United Kingdom (UK) being served by police victim examination suites. OBJECTIVE: To examine variations in service offered to complainants of sexual assault within the United Kingdom in 2005. METHODS: A purpose designed questionnaire sent to all areas of the United Kingdom. Data were received and analysed from 12 of 13 SARCs and 54 of 58 non SARC services. RESULTS: Very wide disparities in service, most marked between SARC and non SARC services. SARCs see a proportion of complainants from non-police sources. The non SARC services do not usually offer a forensic examination without police involvement, and a significant minority have so few doctors that they cannot provide a 24h rota for examinations. Inadequate numbers of forensic physicians are available for child examinations, and a robust service for 'acute child sexual assault' is virtually absent. Photodocumentation with appropriate safe storage is available in all SARCs, while 45% of non SARCs have no facility for photodocumentation. DNA contamination issues were perceived to be significant in many of non SARC services. Most non SARC services for adults do not provide baseline screening for sexually transmitted infection (STI) or offer prophylaxis against STIs. Follow up is by referral to local clinics which complainants may have to arrange themselves. Funded counselling is rare in the non SARCs with the exception of Yorkshire. CONCLUSION: In the non SARC services, lack of co-operative working with local health services, lack of equipment, and lack of 'in house' medical follow up arrangements is the norm. Many areas rely on the good will of a small number of doctors to provide a service without a rota.     

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.     

A survey of case studies on the use of forensic three-dimensional printing in England and Wales

3D printing has rapidly developed and been applied in forensic science due to its use in creating demonstrations for courts of law. Much of the literature on this specific topic has focused on the use of 3D printed models in academia, the potential influence on a jury, and its use as a long-term documentation process, but with few actual forensic case examples. This paper offers an insight into the development of 3D printing in forensic practice and how 3D printing is currently being used in the criminal justice system in England and Wales.

A series of case reports were gathered from multiple police forces and forensic practitioners in the UK to identify how 3D printing was being used. These discussions established who was requesting 3D printed exhibits, what type of technologies were being utilised, what type of exhibits were being printed, and resulting feedback for the use of 3D printed material within a criminal case. As a result, this research demonstrates the current use of 3D printing in England and Wales, discussing the associated cases that have been known to incorporate 3D prints. Likewise, this work explores the limitations that have been encountered by forensic practitioners and identifies a series of research questions that should be considered in future investigations.

     

The relative risk of police use-of-force options: evaluating the potential for deployment of electronic weaponry

An electronic weapon, the Taser M26, has recently entered the use-of-force continuum for police officers in England and Wales and is currently licensed for use by authorised firearms officers only. The aim of this report was to assess the relative risk of injury to officers and subjects of police use-of-force options and to evaluate whether the current positioning of the M26 in the use-of-force hierarchy is appropriate. We analysed use-of-force data from Northamptonshire Police Force and M26 field use data from TASER International. We found officer injury rates associated with M26 deployment were lower than those for CS spray and baton use. Subject injury rates were lower in M26 deployment than in deployment of CS spray, batons or police dogs. We suggest that the M26 should be made more widely available to police officers in the UK.     

Patterns of illicit drug use of prisoners in police custody in London, UK

AIMS AND METHODS: The aims of the study were to explore the current characteristics of drug misusers seen in police custody and identify trends or changes that have taken place in the last decade. A prospective, anonymised, structured questionnaire survey was undertaken of consenting consecutive, self-admitted illicit drug users seen by forensic physicians in police custody within the Metropolitan Police Service in London, UK in 2003. RESULTS: 30% of detainees were dependent on heroin or crack cocaine. Drug users (n=113) were studied in 2003. 95.4% completed the questionnaire. 82% were male, 18% female. Mean age was 28.5 y (range 18-49). 80% were unemployed; significant mental health issues (e.g., schizophrenia) were present in 18%; 15% had alcohol dependence; heroin was the most frequently used drug (93%); crack cocaine -- 87%; mean daily cost of drugs -- heroin GBP 76 (range 20-240), crack GBP 81 (range 20-300). >50% users inject crack and heroin simultaneously. 56% used the intravenous route; 25% had shared needles; 100% had accessible sources of clean needles; 6.4% were hepatitis B positive; 42% were aware of hepatitis prophylaxis; hepatitis C positive -- 20.2%; 3.6% were HIV positive. Mean length of time of drug use was 7.5 y (range 1 month -- 20 years); 82% had served a previous prison sentence; 54% had used drugs in prison; 11% had used needles in prison; 3% of users stated they had started using in prison. 38% had been on rehabilitation programs; 11% had been on Drug Treatment and Testing; Orders (DTTO); 32% had used the services of Drug Arrest Referral Teams in police stations; 10% were in contact with Drug Teams at the time of assessment. CONCLUSIONS: In the last decade, there appears to be a substantial increase in the prevalence of drug use in this population -- particularly of crack cocaine. Treatment interventions are either not readily available, or not followed through. In very general terms, the illicit drug use problem appears to have significantly worsened in the population seen in police custody in London, UK, in the last decade although there is evidence that health education and harm reduction messages appear to have had some positive effects.     

Retrospective cohort study of acute behavioural disturbance in police use of force reports

BackgroundAcute Behavioural Disturbance (ABD) is a presentation of behavioural change which may conceal life-threatening illness. Concerns have been raised that it is used as a justification for deaths in custody and within the health and care system, but there is a lack of evidence exploring how the term ABD is applied in the UK.Aimsto establish how UK police officers apply force in ABD compared to other presentations, examine outcome and fatality data, and identify regional variation and potential systemic issues in the application of the term ABD in a UK setting.Methodretrospective cohort study of 562,280 police use of force (UoF) reports (England and Wales, Apr 2020–Mar 2021).Resultsdifferences were identified in UoF location, co-existing contributors to UoF, justifications given, patient demographics, methods of restraint, and outcomes. Differences were also identified in UoF reports per capita and identification of ABD between police forces.Conclusionwhile there are limitations to the data set and the paper is hypothesis-generating only, this study found evidence suggestive of variations in reporting practices between police forces, and evidence that identification of ABD appears to be associated with protective aims of UoF and more likely to result in a healthcare-focussed outcome. While the majority of ABD was identified in people perceived to be white men, some demographic criteria were associated with an increased relative risk that ABD was identified as a reason for UoF.     

Development of common training units for forensic staff

ABSTRACT

The Victoria Police Forensic Services Department (VPFSD) has prepared guidelines to assist forensic practitioners to develop a common training unit across multiple disciplines.     

In Australia the jury decides:the reliability and validity of expert evidence: a perspective from forensic pathology

ABSTRACT

The Innocence Project has enabled, amongst many other things, quantification of contributors to wrongful convictions in the United States. There, individual cases of wrongful conviction have multiple causes, including problems with forensic expert evidence. The Criminal Cases Review Commission in England and Wales has found that amongst unsafe convictions there, forensic expert evidence has been a feature. Apply the English experience with unsafe convictions to Australia, and there would be many more cases than we know of. The Victorian Supreme and County Court Practice Note on Expert Evidence (2014) has reduced the risk that providers of expert evidence could contribute to wrongful convictions, but more needs to be done. The medical sector generally has a huge research capability and capacity. In comparison the forensic pathology sector is tiny and is characterized more by its focus on managing workloads. Conclusions about the cause of death are not testable, and other opinions provided by forensic pathologists are derived from medical sciences, and not from specific evidence-based research. This does not mean that forensic pathology evidence is inherently unreliable, but it does mean that more work is required to better establish that reliability.     

The impact of contracts on outsourcing computed tomography examinations from a Swedish public university hospital to a private radiology unit

IntroductionAfter years of outsourcing without detailed contracts from one of Sweden's largest university hospitals to external radiology units, the hospital started to use a specific contract for outsourcing computed tomography (CT) examinations. The purpose of this study was to compare the cost-effectiveness of two outsourcing approaches, where examinations were performed either with a detailed, specific contract (with-contract) or without (no-contract), between a hospital radiology department and private external units.MethodsThis retrospective study included a group of electively outsourced CT-examinations (n = 132) and a control group of in-house CT-examinations (n = 132), selected from the three different types of CT-examinations referred from the Departments of Oncology and Hematology.These examinations were randomly selected from four different groups over two time periods of one year each, one being outsourcing without a contract (no-contract, during 2013), one time period with a specific contract (with-contract, during 2014) and two control groups of examinations performed in-house within both these time periods. We compared outsourced examinations (both no-contract and with-contract groups) and in-house examinations. The comparison of these groups include five parameters; management-time, patient waiting-time, the quality of the examinations, - image interpretations and costs.ResultsDuring 2013, management-time for CT-examinations was longer in the outsourced group (no-contract) than in the in-house group, with a statistical significance (P = 0.002). Fewer examinations performed in-house and in the with-contract group needed re-interpretation than in the no-contract group. CT-examinations in the with-contract group were associated with shorter overall management-time, patient waiting time and lower costs compared to the no-contract group.ConclusionUsing a contract with detailed specifications for outsourcing CT-examinations may be an effective way of reducing patient waiting time. Outsourcing based on a well-founded contract can be cost-effective, compared with outsourcing without a detailed plan for the services required.