Independent Office for Police Conduct (IOPC - formerly IPCC)
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IPCC Publishes Report on Near Misses in Police custody

IPCC Publishes Report on Near Misses in Police custody

INDEPENDENT POLICE COMPLAINTS COMMISSION News Release issued by The Government News Network on 12 March 2008

"Adherence to custody policies and procedures saves lives," according to Independent Police Complaints Commission (IPCC) Chair Nick Hardwick.

Mr Hardwick was speaking as the IPCC publishes research today (Wednesday 12 March) that estimates there are around a thousand near misses in police custody in England and Wales every year. Of these 400 were likely to lead to death without prompt intervention by custody and medical staff.

Acute health needs and other risks are a strong feature among those people held in police custody.

Mr Hardwick said:

"Many near misses will be unavoidable. In a number of the cases featured in our report a death was averted due to quick responses from custody staff and forensic physicians.

"However, we believe that more can be done to reduce the likelihood of deaths and near misses. Evidence from our investigations, our work around learning the lessons and this study indicate that there are three areas that police forces need to focus on:

* The need for good quality risk assessment when a detainee enters custody to determine whether detention is appropriate and, if it is, what level of supervision is required.

* Appropriate training for custody staff so that they are sufficiently aware of and are able to identify certain risks among detainees.

* For those responsible for the overall management of custody suites in police forces to reinforce to staff the importance of following procedures and training centring on the care of vulnerable detainees."

Warning against complacency, Mr Hardwick added:

"We need to be careful about how we think about near misses. In many cases the actions of custody staff prevent a death and the individual is left unscathed. However, in some instances they may be seriously and permanently injured. Not all near misses end happily.

"Adherence by custody staff to PACE and associated policies saves lives. This message needs to be reinforced to custody staff who need to follow set procedures, such as rousing and checking."

Jason Payne-James, a co-author of the IPCC report and Vice President, Faculty of Forensic and Legal Medicine said:

"The way to reduce deaths and near misses in police custody is through good risk assessment and better healthcare provision. Forces need to ensure that their custody staff are adequately trained to identify the healthcare issues they are likely to face on a day to day basis."

The IPCC study, Near Misses in Police Custody, examined incidents which resulted in or could have resulted in the serious illness or self-harm of those held in police custody. It was carried out in collaboration with forensic physicians working within the Metropolitan Police Service and examined their experiences over the period May 2005 to April 2006. The results were used to calculate an estimate of the number of near misses that occur across England and Wales and the report makes 11 recommendations for all police forces.

Key Findings
A total of 121 near misses were reported within the MPS during the period of the study. The severity of these varied:
* In 50 of the 121 incidents (41%) forensic physicians felt that if the incident had not been responded to, death was very likely or fairly likely.
* Twelve detainees (10%) had to be resuscitated in the custody suite.
* Fifty-nine (49%) were taken to hospital as a result of the incident, and 27 were detained there for observation or treatment.

There were six deaths in custody in the MPS and 28 deaths in custody in England and Wales during the period of the study.

Based on these figures the IPCC has estimated that there may be approximately 1,000 near miss incidents in police custody each year, with approximately 400 of these being cases where death was very likely or fairly likely.

Circumstances of Incidents
The most common incidents involved:
* Attempted suicide/self-harm (46%)
* Drugs consumption or possession (33%)
* Medical conditions (14%)
* Alcohol consumption (7%)

Just over half of the incidents (56%) occurred in the 12-hour period between 7pm and 7am. The greatest number of incidents were reported on a Wednesday and a Thursday.

Key Factors in Incidents
Forensic physicians identified the following factors in having a negative impact on the incident:
* Searching (in 28% of incidents) - for example items not removed from the detainee or a cell played a central role in a near miss.
* Custody staff levels (in 15% of incidents) - for example low numbers of custody personnel and high volumes of detainees may have played a part in these incidents occurring.
* Checking/rousing (in 11% of incidents) - for example custody staff not following the requirements set out in PACE.

Forensic physicians identified the following factors as having a positive factor on a near miss:
* Checking/rousing (in 31% of incidents)
* Speed of request for a forensic physician (in 20% of incidents)
* Custody staff levels (in 18% of incidents)

These positive factors suggest that the ability of staff to monitor detainees and follow procedures contributed to near misses being identified and managed.

Commenting on the national relevance of this study, Mr Hardwick said:

"It would be unwise to assume that these issues relate only to the MPS. It is likely that these are general issues for those managing and working in custody suites across England and Wales.

"I would like to thank the MPS for collaborating in this piece of research. It could not realistically have been done in any other police force due to the number of custody detainees required. The MPS' participation in a potentially controversial study reflects its level of commitment with regard to the proper management of detainees in custody."

Recommendations to all Police Forces
The IPCC's report makes 11 recommendations to the police service.

Recommendation 1: for those responsible for custody policy in police forces to consider whether custody staff are fully aware, or need to be reminded via guidance and training about the appropriate responses to drug swallowing and severe intoxication. Likewise the message needs to be reinforced that apparent symptoms of intoxication may in fact be the result of an injury or medical condition, and that intoxication may mask or be found in conjunction with serious health needs.

Recommendation 2: for police forces to consider whether Custody Officers have been provided with sufficient guidance on the management of those detainees who are either unwilling or not able to participate in a risk assessment.

Recommendation 3: for police forces and health service providers to ensure that Custody Officers and Forensic Medical Examiners are provided with a record of treatment for detainees returning from hospital. This may require discussion between the two organisations about the best way to communicate any treatment information, and if a method exists already, to ensure that hospital staff are aware of their role in this practice.

Recommendation 4: for police forces to ensure that Custody Officers are aware of the importance of checking cells when they are vacated and the need to remove items which could be used to self-harm by later occupants.

Recommendation 5: for police forces to ensure that Custody Officers have ready access to ligature knives.

Recommendation 6: for police forces to ensure that Custody Officers are aware of the requirements for the monitoring and observation of detainees as outlined in PACE Code C and national guidance on 'The Safer Detention & Handling of Persons in Police Custody'.

Recommendation 7: for police forces to ensure that Custody Officers are clear that 'rousing', as outlined in PACE Code C, means eliciting a verbal or physical response from the detainee.

Recommendation 8: for Forensic Medical Examiners to be aware of the danger of detainees stealing medication during consultations and to take precautions to avoid this occurring.

Recommendation 9: for those responsible for managing custody suites to consider whether the flow of detainees at peak times compromises custody staff's ability to follow PACE Code C and to plan appropriately for such occasions.

Recommendation 10: for police forces to ensure that Custody Officers, as part of their training, gain sufficient awareness of the symptoms of key conditions, involving substance misuse and health conditions, to be able to conduct robust risk assessments.

Recommendation 11: for police forces to consider developing ways in which near misses in custody can be reported to those with responsibility for managing custody policy and procedures.

Near Misses in Police custody: a collaborative study with Forensic Medical Examiners in London, IPCC, London, ISBN 978-0-9556387-0-1 can be found on the IPCC website at

Notes to Editors:
1. To aid reporting in this study the specific details and locations were omitted from the recording of the incident. This means it is unclear how many cases were referred to the IPCC. However, it is highly likely that the vast majority of near misses were not referred as they would not have met the threshold of serious injury to the detainee.

2. The IPCC has had overall responsibility for the police complaints system since April 2004. Since April 2006 it has taken on responsibility for similar, serious complaints against HM Revenue and Customs and the Serious Organised Crime Agency in England and Wales. It took over responsibility for the way serious incidents and complaints involving Border and Immigration Agency (BIA) staff are handled in February 2008.

3. The IPCC has the task of increasing public confidence in the complaint systems and aims to make investigations more open, timely, proportionate and fair.

4. The 15 Commissioners who run the IPCC guarantee its independence and by law can never have served as police officers. No Commissioner has worked for HM Revenue and Customs or BIA. They are supported by more than more than 200 independent IPCC investigators, casework managers and other specialists.

5. The IPCC is committed to getting closer to the communities it serves. Its Commissioners and staff are based in IPCC regional offices in Cardiff, Coalville, London and Sale plus a sub office in Wakefield.

6. The IPCC web site is constantly updated at

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