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 http://www.ipcc.gov.uk/index/resources/research/stats.htm
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 http://www.ipcc.gov.uk