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.     

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.     

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.     

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.     

Guidelines for doctors attending detainees in police custody: a consensus conference in France

Medical practice in police custody needs to be harmonized. A consensus conference was held on 2–3 December 2004 in Paris, France. The health, integrity, and dignity of detainees must be safeguarded. The examination should take place in the police station so that the doctor can assess the conditions in which the detainee is being held. If the minimum conditions needed for a medical examination are not available, the doctor may refuse to express an opinion as to whether the detainee is fit to be held in custody or may ask for the detainee to be examined in a hospital. Doctors are subject to a duty of care and prevention. They should prescribe any ongoing treatment that needs to be continued, as well as any emergency treatment required. Custody officers may monitor the detainee and administer medication. However, their role should not be expected to exceed that required of the detainee’s family under normal circumstances and must be specified in writing on the medical certificate. Doctor’s opinion should be given in a national standard document. If the doctors consider that the custody conditions are disgraceful, they may refuse to express an opinion as to whether the detainee is fit for custody.     

Evaluation of problematic psychoactive substances use in people placed in police custody

Introduction and aimsIn France, the law states that any person held in custody could be examined by a doctor. The main objective of the medical examination is to give medical evidence of health compatibility with custody. This review identifies health risks such as addictive behaviour. We wanted to know which psychoactive substances are used in this particular population, and how problematic these uses are.Design and methodsA prospective, monocentric, open-ended study conducted via a structured questionnaire was carried out on detainees who reported having taken drugs or illegal substances. Practitioners investigated desired effects for each substance, and characteristics of use, by means of the dependence criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (American Psychiatric Association, 1994). Problematic use was assessed when at least 3 items of the DSM IV were positive.Results604 questionnaires were examined. 90.7% of questionnaires reported tobacco use, 76.2% cannabis, 57.3% alcohol, 12.5% psychostimulants, 10.0% opiates and 0.7% benzodiazepines or Z-drugs. The frequency of problematic use was 74.6% for opiates, 44.9% for cocaine and 25.3% for cannabis. Compared to non-problematic users, problematic users were older, more likely to be jobless without financial means, more likely to have a medical history, including a greater likelihood of mental illness, and more chance of undergoing prescribed medical treatment. They included more women and more homeless people.Discussion and conclusionsThese results show characteristics of psychoactive substance use in a sample of people in custody. Psychoactive substances mentioned by respondents are not different from those observed in the general population, but for certain users, the desired effects are far from the pharmacologically expected ones. For some, taking substances seems to be part of their way of life, for others it is a means to compensate for an underlying feeling of uneasiness. Furthermore, problematic users present severity criteria which seem to be greater than in psychoactive substance users in the general population.     

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.     

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 identification and treatment of opiate users in police custody

All detainees admitted to seven London police stations were observed over a six-month period (n=2,947). Four per cent were identified as opiate users, although the actual percentage is likely to be much higher. Compared to the general population of detainees there were significantly more women among known opiate users and this group also contained a higher percentage of white detainees and people born in the British Isles. People born in continental European countries were also over-represented. A little more than half of known users did not reveal their use on arrival at the police station. At least 60% of known opiate users remained well throughout their detention, 30% were intoxicated through drugs at the time of their arrest, but only 13% displayed signs or symptoms of withdrawal during their detention. Overall, 65% of the known opiate users were seen by a police surgeon and of these 52% were given medication. All of those withdrawing were given drug treatment, but most of those who were intoxicated by opiates, or who remained well throughout their detention, received no medication. Of those given medication 86% received an opiate, dihydrocodeine being the commonest preparation, usually in association with a benzodiazepine. Despite the adoption of differing management paradigms among police surgeons, the actual medical treatment of opiate-using detainees was pragmatic and determined by individual need.     

Detainees in Amsterdam,a target population of the Public Mental Health System?

The Forensic Medical Service of the Public Health Service offers health care to detainees in police cells in Amsterdam. This study describes the registered mental health, addiction and social problems and compares them to the self-reported problems among a sample of detainees. Registers of the Forensic Medical Service are related to information from registers of police detention episodes. A general assessment of substance use, mental health and social problems is obtained by interviewing a sample of 264 detainees. The Forensic Medical Service was contacted in 24% of the 17,321 detention episodes. In 14% of the episodes mental or substance related disorders were observed. Within the sample 59% scored positively on indicators of substance abuse or mental health problems, 35% had additional social problems (debts, unemployment, housing). This proportion increased with age. It is concluded that substance abuse and mental health problems combined with social problems are highly prevalent among detainees, especially among the older ones. This urges for a close cooperation between Public Mental Health Care and Forensic Medical Services.     

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.     

Audit of hospital transfers January to March 2006 from Sussex police custody

The aim of this audit was to determine a baseline for timing, numbers and case mix of detainees referred to hospital for medical assessment in order to review the effectiveness of existing custody procedures for the management of medical emergencies.Data was examined for the 3-month period January to March 2006. A total of 12015 detainees were processed during this period, 188 patients identified as requiring hospital assessment, a hospital transfer rate of 1.57% for the period, 80 cases (0.65%) were for potentially life threatening conditions. The health care team assessed 37.7% of all detainees and were recorded as involved in 151 of the 188 cases transferred (80%).The categories of patients sent to hospital included head injury (26/188 or 13.8%), overdose and poisoning (20/188 or 10.6%); chest pain (17/188 or 9.0%), collapse (12/188 or 6.4%), unrousable intoxicated (10/188 or 5.3%), possible drug swallowers (7/188 or 3.72%), breathing problems (4 or 2.12%), acute confusional state (3/188 or 1.6%), 2/188 had a query deep vein thrombosis, one diabetic problem and one acute allergic reaction. The largest category of all was for a miscellany of minor injury unit care.     

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.     

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.     

Prevalence and medical risks of body packing in the Amsterdam area

AimBody packing is a way to deliver packets of drugs across international borders by ingestion. The aim of the study was to provide an estimate of the medical risks of body packing, describe predictors for hospital referral in detained body packers and provide an estimate for the prevalence of body packing in the Amsterdam area.MethodsFrom May 2007 to December 2008, we studied medical records of body packers immediately detained after arrival at Amsterdam Schiphol airport, hospital records of both detained body packers and self-referrers at two emergency departments of hospitals in Amsterdam and records kept by forensic physicians in charge of post-mortem examinations of all unnatural deaths in the area (years 2005–2009).ResultsIn airport detainees, the hospital referral rate was 4.2% (30 out of 707 detained body packers), the surgery rate was 1.3%. Significant predictors of hospital referral were delayed production of drug packets after arrest, cigarette smoking and country of departure. The surgery rate in self-referrers was comparable to the rate observed in those referred from the detention centre to hospital (30% vs. 31%). In addition, from 2005 to 2009, 20 proven cases of lethal body packing were identified. Based on our data, it is estimated that minimally 38% of all incoming body packers were missed by airport controls.ConclusionThe risk for lethal complications due to body packing is low on a population basis and comparable to other studies. This also applies for the hospital referral and surgery rates found in this study. Cigarette smoking has not yet been described in the literature as a potential predictor for hospital referral in detained body packers and therefore deserves attention in future research. A substantial fraction of body packers manages to remain undiscovered.     

The work of forensic physicians with police detainees in the Canberra City Watchhouse

Forensic physicians provide both medical care and forensic consultations to detainees in police custody. There is a paucity of Australian data regarding characteristics of detainees and the type of work provided by forensic physicians in this setting. This retrospective audit of a clinical forensic service in Canberra, Australia will assist with service planning, future data collection and the training of forensic physicians.     

A prospective survey of section 136 in rural England (Devon and Cornwall)

The Mental Health Act 1983 gives the police the power to remove those persons who appear to be mentally disordered from a public place to a place of safety. Previous studies have shown conflicting results concerning its use and there have not been any previous studies in a rural area. This study is a prospective survey of the use of Section 136 in SW England and was carried out between October and December 2000 in six custody centres in SW England. Each detainee had a study form completed to examine how the section was being applied, specifically looking at the time taken for the assessment to be complete and the outcome. The results showed that there were 178 detentions under Section 136 over the three-month study period. It took 25 minutes for detainees to arrive at a police custody unit and the assessments took about 8 hours to complete. The longest delay was for the approved social worker to arrive at the custody centre, (3h 25m) which was significantly longer than the arrival time of the Section 12 doctor (2h 10m). After assessment 32% of Section 136 detainees were admitted to hospital. There were differences between the conversion rates between the six custody centres although these were not significant. This study's conclusions suggest that although rural areas meet the statutory maximum time limits for completing Section 136 assessments, greater distances than in inner city areas lead to substantial delays in completing assessments. Also this study found a much lower rate of hospital admission after assessment than has been found previously and this may reflect the differing needs and characteristics of a rural population compared with the inner city populations.