warwickshire and west mercia police custody health needs...
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Warwickshire and West Mercia Police Custody Health Needs Assessments
Damian Mitchell, Director, UHWUK
Malcolm Pearce, Director, IHWUK
Professor Charlie Brooker, Honorary Professor of Mental Health and Criminal Justice,
Royal Holloway, University of London and Associate IHWUK
Professor Karen Tocque, Honorary Professor of Health intelligence at Glyndwr University
and Associate IHWUK
November 2013
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Acknowledgements
We would like to thank the project steering group for their help and guidance, throughout the project: Mark Ritchie Project Manager Warwickshire Police Becki Hipkins Project Manager Health and Justice (West Midlands) NHS England Nicola Wright Consultant in Public Health - Wider Determinants of Health Public Health Warwickshire, Communities Group Warwickshire County Council We would also like to thank the Custody Inspectors from the two forces who helped to facilitate the site visits: West Mercia: Peter Jones Helen Beer Steve Turner Warwickshire Ben Smith Andrew Timms We are grateful too, to all the staff who gave freely of their time in order that we might understand how healthcare 'worked' across the Warwickshire and West Mercia areas. Finally, we wish to thank Geoff Wilson, Performance Information Manager, Warwickshire and West Mercia Police for his help in accessing the data for analysis.
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Executive Summary
IHWUK CIC were commissioned by Warwickshire and West Mercia Strategic Healthcare
Partnership to map the health needs of detainees in police custody suites within the
Warwickshire and West Mercia police force areas, and investigate the extent to which they
are being met by existing service provision.
Methodology The project was undertaken in 3 modules:
Module One Interviews and corporate needs assessment Face to face interviews were conducted with a range of key stakeholders within the two
major police custody suites in Warwickshire and West Mercia. The aim of the face-to-face
interviews was to obtain an initial description of the police station and the services currently
being provided there.
In addition, participants were asked to provide the interviewers with copies of relevant
policies/procedures to allow them to map the range of services available in each setting and
their referral routes.
A literature review was also undertaken in support of the corporate needs assessment to
include an overview of healthcare related findings from the most recent HMIC
inspection/relevant inspections/reviews.
Module 2 Data Linkage: FME Involvement with Detainees
Datasets: datasets supplied and processing were:
1) Both West Mercia Police and Warwickshire Police provided two datasets:
a. one containing all detention records for 2012 along with the custody risk assessment; and
b. one containing all detentions which had an FME assessment, along with the response.
All custody records from the two forces were merged into a single dataset covering 2012 and
the unique custody detentions were extracted based on the ‘Custody Record Number’1
. A
separate file was constructed to contain the Custody risk assessment for each detention.
1 First the Warwickshire dataset was cleaned to populate the ‘Custody Record number’ for every Risk Assessment relating to that Custody record – as it was supplied with just the initial record completed
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The data were manipulated using MS Access and MS Excel for data linkage and cleaning
then analysed using SPSS v20. Descriptive univariate statistics were produced initially and a
multiple logistic regression was used to determine the odds ratio of the significant factors
that predict seeing an FME whilst being held in custody.
Module 3 Detainees’ Views of Healthcare The third strand consisted of self-report questionnaire data from a convenience sample of
detainees on their health status, access to services and preferences for care.
Main findings Basic demographics
• Over all of 2012, there were around 32,000 detentions at Warwickshire & West Mercia’s custody suites combined
• Of these, 84% were male and 16% female • Only 4,377 (14%) did not have a postcode of residence recorded, and could
therefore not be allocated to a local authority or deprivation quintile • Of detainees with a valid postcode, the majority (51%) lived in the two most deprived
quintiles of areas; only 8% were from the most affluent quintile. • Of these, 85% were residents of Warwickshire & West Mercia. There was a wide
distribution of residency of all detainees at Warwickshire & West Mercia’s Custody suites.
• Overall, 18,300 (68%) of detainees were aged under 35, with around 4,000 (14%) aged 10-18 and just 1,200 (4%) aged 45+.
Response times Issues concerning the ability of the new provider ‘Primecare’ to send staff to deal promptly
with health issues of detainees were cited by staff in all custody suites as a problem, across
both West Mercia and Warwickshire areas. There was some acceptance that these were
“early days” for the new contract but a general feeling expressed that the fundamental issues
of lack of staff resource to fulfil the contract and geography made it unlikely that the
problems would be resolved in the short to medium term.
Call Centre There was a general feeling of dissatisfaction with the new call centre
Extended role for ‘Health Care Professionals’ Most custody staff interviewed believed that “in an ideal world”, custody suites would be
staffed by a nurse on-site, with on call medical cover, as this would resolve the majority of
problems relating to response times. Such a model could be investigated for future
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contracts, as happens with other forces but would require nurses/healthcare practitioners to
be able to undertake a greater variety of tasks.
Culture and relationships Custody staff showed a very positive attitude towards providing a safe place of custody and
took their responsibilities to provide ‘care in custody’ seriously. Relationships between the
police and local A&E departments were reportedly as generally poor. Police staff stated that
they often spent 4 or 5 hours waiting in A+E for a detainee to be assessed and treated,
which this ties up two officers.
Custody staff stated that it was far from unusual for suspects to be bailed or ‘no further
action’ taken whilst attending A+E for operational reasons (staff pressures) even, in some
instances, before investigations into the offence had taken place - although it was stressed
that this would only happen for minor offences. There was no evidence of the existence of
joint-working protocols between A&E departments and the police
Primary Care Pathways There is no link between Healthcare professionals and NHS Primary Care, no access to
primary care information systems and no clear referral pathway from custody to the
community.
Discharge forms from A+E Discharge forms from A+E, setting out what treatment has been given to the detainee in the
department are often not completed.
Treatment setting There is a need for a clear set of policies that stipulate when a detainee should attend A&E,
because more treatment could potentially be provided in police custody, thus reducing the
burden on the police and the NHS.
Roles of Medical and Nursing Staff The guidelines by the provider on the role of the FME and Custody nurse (for West Mercia)
are not well known to known to police custody staff and this has led to some confusion over
roles and responsibilities and the suggestion that in many instances, doctors are called out
when a nurse could carry out the procedure.
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Refusal of medical staff to ‘multi-task’ It was reported that medical staff covering the West Mercia force area, are often reluctant to
‘multi-task’ (e.g. undertake routine procedures that would normally be carried out by a
nurse), with consequent delays in getting detainees treated.
Administration of methadone It is a provider policy that only doctors can dispense methadone, which can lead to delays
because of the previously described response times for medical staff. This approach seems
outdated and unnecessary, as, under the 2012 revisions to PACE (1984) methadone can be
dispensed either by a forensic medical examiner (FME) or custody care practitioner (CCP) –
e.g. a nurse.
Treating Head Injuries The treatment of head injuries, was a frequently occurring problem in all sites and a
significant drain on staff resources, as it requires two officers to escort the detainee to the
A+E department.
Administration of medication A number of detention officers were uncomfortable about administering medication without
any basic training on drugs and their side effects.
Mental Health The approach to dealing with the mental health issues of detainees was very different across
the two force areas. Warwickshire has a well established ‘Liaison and Diversion’ service
(although funding is not secure) but West Mercia does not. Even with the existence of
Liaison and Diversion Services, there are still significant issues relating to the management
of the mental health problems of detainees.
Custody staff experience difficulties in dealing with the mental health problems of detainees
out of hours, as not all doctors on the rota are section 12 approved.
New protocols have been put in place in both police areas for dealing with detainees who
have been detained under Section 136 of the Mental Health Act. In both areas, this has
been viewed generally positively but some problems still remain in terms of capacity and
attitudes and procedures for the joint management of risk.
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There is not a common understanding or approach for dealing with detainees who may have
a Learning Disability, Asperger’s or Autistic Spectrum Disorders.
Drugs and alcohol The Drug Intervention Programme (DIP) seen to be generally working well (accessible) in all
areas, however large increases in worker caseloads in recent years is felt to be impacting on
the quality of the service, with far less time available for one-to-one work.
Drug workers stated that often mental health services won’t take on clients if still using
alcohol and drugs and there is no protocol in place to manage ‘dual diagnoses’ between
agencies.
Few referrals to the DIP service have come via Primecare staff.
Communication and IT At the end of the second month into the Prime care contract the medical computer system
still does not work.
Appropriate adults There is no commissioned ‘Appropriate Adult’ service in either force area. West Mercia, has
access to a volunteer service which it is hoping to expand but there is no dedicated
appropriate adult service in Warwickshire and this was identified as a problem by some
custody staff.
Training Officers receive basic training on first aid but would welcome more face-to-face training
provided by healthcare professionals to improve their understanding of common health
problems including mental health, physical health (e.g. diabetes, asthma), medication and
substance misuse.
See section 4 below for a summary of recommendations
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Contents
1. Introduction 11
2. Findings
Module 1 11 - 41
Literature Review
HMIC Inspection Reports
An Overview of Warwickshire and West Mercia Police Forces
Staff Interviews with Police and Health Providers
Module 2 Data Linkage: FME Involvement with Detainees 42 - 61
Module 3 Detainees’ Views of Healthcare 61 - 63
3. Summary of Recommendations 64 - 66
4. Conclusion 66
5. References 67 - 68
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List of Tables
Table 1 Travelling times between the key West Mercia Custody Suites
Table 2 Travelling times between the key Warwickshire Custody Suites
Table 3 Local demographic data for Warwickshire & West Mercia Police areas
Table 4 Summary of detainees responses to their health concerns
Table 5 Summary of the extent to which the help detainees were offered met
their needs
Table 6 Summary of health professionals seen by detainees
List of Figures
Figure 1 Demographics of all detainees in custody suites across Warwickshire & West Mercia, 2012 (where postcode is recorded, n = 12,325)
Figure 2a Local Authority of residence of all detainees at Warwickshire & West Mercia custody suites during 2012 (with valid postcode, n = 27,527)
Figure 2b Local Authority of residence of all detainees at Warwickshire & West Mercia custody suites during 2012 (with valid postcode, n = 27,527)
Figure 3 Age-standardised rates of detention in Warwickshire & West Mercia
residents by a) Index of multiple deprivation and b) Local Authority.
Figure 4 Basic demographics by age of detainees in custody suites across
Warwickshire & West Mercia 2012
Figure 5 Proportion of detainees seen by an FME by basic demographics (Custody data
records only – not linked to Medacs)
Figure 6 Proportion of detainees seen by an FME by other potential predictors (Custody
data records only – not linked to Medacs)
Figure 7 Proportion of detainees seeing an FME or not by basic demographics (Custody data records only – not linked to Medacs)
Figure 8 Proportion of detainees seen by an FME or not by Home Office crime category
Figure 9 Proportion of detainees seen by an FME or not by positive response to Custody assessment
Figure 10 Summary characteristics of whether detainees are seen by the FME - Multiple logistic regression statistics
Figure 11 Summary of reasons detainees saw the FME and the main reason for the call out
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Figure 12 Reasons for being seen by an FME by a) Custody suite and b) age (from Medacs data for West Mercia only)
Figure 13 Proportion of detainees having a medical assessment due to mental health issues by area of residence (from Medacs data for West Mercia only)
Figure 14a) Location (residence) of FME call out due to Mental Health (where postcode is recorded, n = 268)
Figure 14b) Location of FME call out due to Mental Health Issues, Warwickshire & West Mercia residents (where postcode is recorded, n = 268)
Figure 15 Summary characteristics (predictors) of being seen by the FME for Mental Health assessments - Multiple logistic regression statistics
Figure 16 Outcome of medical assessment by FME
List of Appendices Appendix 1 List of Interviewees for Custody and SARCs Visits
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1. Introduction
This Health Needs Assessment has been commissioned in the following context:
'The national Police Early Adopter Project is piloting over the next two years partnership working between the Police and the NHS in the commissioning of healthcare in police custody suites. This is being undertaken with a view to determining whether statutory responsibility should transfer, as it has for prison health, to the NHS National Commissioning Board.
Warwickshire and West Mercia PCCs and NHS England Health and Justice are part of Wave 2 of the Early Adopter Project and have entered into a partnership to commission healthcare services within police custody suites. A new healthcare service provider will commence on 1 September 2013, covering Warwickshire and West Mercia providing healthcare assessments, forensic examination and evidence retrieval, treatment, signposting and onward healthcare referral for any detainee brought into custody. The provider will also deliver forensic medical examinations within Sexual Assaults Referral Centers (SARCs)'. 2. Findings
Module 1
1. Literature Review
Police custody and health
Individuals detained in police custody may be in need of a medical examination or a health
intervention for a variety of reasons; including assessing injuries sustained prior to detention,
providing medication, assessing their need to be transferred to a hospital for treatment,
assessment of drug/alcohol use, collection of samples (for example in sexual assault cases),
assessment of competence, and assessment of whether they should be accompanied by an
Appropriate Adult (BMA, 2009). Indeed, police custody arguably provides a key point of
contact with health services for individuals who may otherwise be hard-to-reach and whose
contact with health services may be inversely proportionate to their level of need (DH, 2007;
Bradley, 2009). It is a concern, therefore, that in his review of people with mental health
problems or learning disabilities in the criminal justice system, Lord Bradley described police
settings as “the least developed in the offender pathway in terms of engagement with health
and social care services” (2009: 34).
The basic legal framework within which custody services operate is provided by the Police
and Criminal Evidence Act 1984 (PACE) and the associated Codes of Practice, specifically
Code C. Further guidance has been provided by the Association of Chief Police Officers
(ACPO), notably the Guidance on the Safer Detention and Handling of Persons in Police
Custody (2006), which, although not a legal requirement, is the yardstick against which
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police are judged by investigating authorities or during litigation in the event of an adverse
incident in custody. More recently, further guidance in relation to mental health issues has
been provided in Guidance On Responding To People With Mental Ill Health Or Learning
Disabilities (2010).
Traditionally, custody sergeants have completed a risk assessment with detainees to decide
whether they are in need of healthcare or of an Appropriate Adult, and, when needed,
healthcare services have been provided by registered medical practitioners (often called
‘forensic medical examiners’).
To date, very little research has been conducted into the health needs of detainees in police
custody. The NEOHCU is also currently working with North Yorkshire Police, who are one of
a number of police force early adopters nationally, on the shadow transfer of the
commissioning of their detainee healthcare to the NHS. A shadow transfer period has been
established to enable the commissioner and police to assess the environment, undertake
due diligence and establish working relationships before the NHS takes over the
commissioning and budgetary responsibility in April 2015.
The small volume of existing literature in this area points to detainees experiencing a wide
range of health conditions, many of which need active support whilst in custody.
For example, in their questionnaire survey of 168 detainees seeing a Forensic Medical
Examiner (FME) in police custody in London, Payne-James et al. (2010) found that 56% of
their sample had ‘active medical conditions’ in need of management whilst in detention. They
state that, “mental health issues and depression predominated, making up 32% of such
issues, but there was a very large range of complex, mixed disease and pathology” (2010:
16). Of the seventy (78%) of these individuals who were on prescribed medication, thirty-five
were not taking it regularly. Overall, detainees reported dependence on a range of
substances, with 33.9% being heroin-dependent, 33.9% being dependent on crack-cocaine,
25% on alcohol, 16.6% on benzodiazepines, and 63.1% on cigarettes. A less severe need
for healthcare was identified by Sirdifield and Brooker (2012) in a health needs assessment
undertaken in Northumbrian custody suites. In this paper, the healthcare records of a
random stratified sample of 1,917 detainees were analysed, of whom 23% saw an FME. The
majority of calls were made for the FME to assess fitness for detention (69%), fitness for
interview (27%), the prescription of drugs (21%), injury (13%), and mental health (11%).
Similarly, using anonymised police records for detainees seeing a FME in the London
Metropolitan area, McKinnon and Grubin (2010) highlight a wide range of physical and
mental health problems experienced by this group. In addition, this study pointed to
statistically significant differences between the recording of drug, alcohol and mental health
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problems by custody sergeants and the recording of the same problems by FMEs –
suggesting that relying on risk assessments completed by custody sergeants alone may
produce an under-estimation of the extent of health problems experienced by detainees.
This issue is also identified in the Bradley Review, and in a health needs assessment of
detainees in police custody in West Yorkshire. In the West Yorkshire project, police custody
records from April 2008 to March 2009 were analysed to investigate the range of physical
and mental health problems reported. The most frequently recorded physical health
complaint was asthma, affecting 14% of detainees. The most frequently recorded mental
health problems were depression (70.7%) and history of self-harm (47.8%). Overall, 38.2%
of detainees had a dual diagnosis; that is, had both a mental health and a substance misuse
problem. The author notes, however, that the risk assessments are based on self-report in
an environment which may be conducive to under-reporting of health problems which carry a
stigma. Furthermore, detainees are often admitted under the influence of drugs and/or
alcohol, making identifying other health problems problematic. This is likely to be further
compounded by a lack of mental health awareness training (Bradley, 2009).
There have also been several studies of new models of healthcare provision in police
custody settings (see for example: Bond et al., 2007; Viggiani et al., 2010; Elvins et al.,
2012). Elvins et al., (2012) studied the introduction of nurse-led healthcare in police custody
settings in Tayside. This study provides some insight into the range of healthcare problems
likely to be experienced by detainees as it found that nurses undertook a wide range of
activities with detainees; including administration of medication, offering brief alcohol
interventions, injury assessments, substance withdrawal management, and mental health
assessments. These studies also point to the potential for services which include custody
nurses to reduce response times and for nurses to take on some of the functions which have
traditionally been provided by FMEs, thus allowing FMEs to focus on the more complex
forensic cases (Bond et al., 2007) – an area which is further explored later in this report.
2. Inspections of current service provision
Forces are subject to a rolling programme of thematic inspections by Her Majesty’s
Inspectors of Constabulary to ensure compliance with legislation and best practice, and the
Warwickshire and West Mercia Forces were subject to such inspections of their custody
facilities and practices in December, 2009 (WM) and October 2009 (W). The following
section summarises existing health service provision across the two forces at the times of
these reports, drawing on the findings of the above thematic inspection. It should be borne in
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mind that the inspections are out-of-date as the visits were undertaken at least three years
ago.
Warwickshire
The summary of healthcare below is quoted directly from the HMIC Custody Inspection
report completed in October, 2009 (HMIP and HMIC 2009a).
Summary of healthcare: The forensic medical examiner (FME) service was provided by local
GP practices under individual contracts. Doctors also worked for their own practices, which
caused conflicts and delays. Some consultations were cursory and others took place over
the telephone. Not all the medical rooms were fit for purpose and medicines management
was inconsistent. There were no defibrillators, oxygen or suction kits and some first aid kits
were not fully stocked. Detainees could continue to receive prescribed medications,
including Methadone. The security of the doctors’ clinical records did not comply with data
protection or Caldicott guidelines. Addaction provided substance misuse services, including
a specialist alcohol worker. Custody staff relied on forensic community psychiatric nurses to
liaise with mental health services, but their funding was under threat. There were no section
136 beds in Warwickshire, so detainees held under the Mental Health Act were routinely
held in custody until assessments could take place. There was some good analysis of the
statistics relating to section 136 detainees
Recommendations 1. Forensic medical examiners (FMEs) should not work for any other organisation, including working as a GP, when on call for FME duties. 2. Female detainees should be able to see a female FME on request. 3. The contract monitoring of health services should include monitoring to ensure that robust clinical governance arrangements are in place, such as General Medical Council registration, continual professional development and appraisal. 4. All FME rooms should be fit for purpose and contain all necessary equipment . 5. There should be clear infection control procedures, including cleaning schedules that should be adhered to and monitored. 6. There should be safe pharmaceutical management and use of all medications. All medications should be stored safely and securely and any not consumed should be disposed of safely. 7. Medications should not be issued to police staff unless prescribed by an FME after an accident or injury. 8. Resuscitation equipment should be available in each custody suite. It should be
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checked at least weekly and there should be documentary evidence that such checks are completed. 9. All staff should be able to use the resuscitation equipment and have at least annual updates. 10. Response times of medical examiners should be monitored and challenged if deemed unacceptable. 11.All clinical staff working regularly in custody should have individual ‘log in’ details for NSPIS. 12. Forensic medical examiners should ensure that all clinical records are stored in accordance with the Data Protection Act and Caldicott guidance. 13. The forensic community psychiatric nurse service should be adequately funded to ensure care for detainees with mental health needs. 14. Police custody should not be used as a place of safety for those detained under Section 136 of the Mental Health Act. 15. Discussions involving the care of detainees with mental health issues should continue involving the strategic health authority or department of health (offender health) if necessary. Housekeeping points 1. The medical rooms should be locked when not in use. 2.Sharps bins should be dated and signed when first used. 3. There should be regular checks of all stocks to ensure that they are not out of date. 4. To avoid contamination, medications should not be handled. 5. Staff should have access to up to date medical reference books such as the British National Formulary. Good practice 1. The presence of forensic community psychiatric nurses in the custody suites and their availability to provide advice and organise mental health assessments was an example of health and custodial services working together to provide care for detainees with mental health issues. 2. The breakdown and analysis of information on detainees held under section 136 of the Mental Health Act was an example of what evidence can be collected and used and could be undertaken by other forces.
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Warwickshire Summary - 2009 HMIC Inspection Report (HMIP and HMIC 2009a): On the
last occasion that custody suites were inspected it is clear that were concerns about the
FME model that was being utilised; cleanliness of the clinical areas; the medication policies
being employed; and the storage of clinical records. In the area of mental health, the CMHNs
provided a good service but funding was under threat, and at the time, there was no Section
136 places of safety. Competent substance misuse services were being provided by
Addaction.
West Mercia
The summary of healthcare below is quoted directly from the HMIC Custody Inspection
report completed in December, 2009 (HMIP and HMIC 2009b).
Summary of healthcare: There were no formal clinical governance arrangements for health
services in custody and no clear service specifications or contracts. This situation is
unacceptable and had produced inconsistent provision and prevented effective quality
assurance. There was no evidence of any formal monitoring of response times or recording
of doctors' training, registration or indemnity. With the exception of Telford, there were out-
of-date medications in all the suites visited and records of stock were unreliable. Clinical
equipment in medical rooms varied significantly, as did arrangements for detainees with
substance use issues.
Recommendations:
1. Female detainees should be able to see a female health professional on request. 2. The clinical examination rooms should be appropriately equipped, used only by health professionals, and fit for purpose at all times. 3 There should be arrangements for the prevention and control of infection, informed by risk assessment, audit and monitoring systems, with appropriate learning from findings, action planning and timely implementation. 4 There should be safe and effective medicines management supported by clear protocols governing ordering, storage, prescribing, administration, destruction and audit. 5 Secondary dispensing of medications should cease . 6 Resuscitation equipment should include oxygen and effective suction equipment. Staff should be trained in resuscitation techniques. 7. Under current legislation, police and detention officers should not administer or supervise the self-administration of methadone
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Housekeeping points 1. All defibrillators should have defibrillator pads that are fit for use. 2. The forensic medical examiner rooms should be locked when not in use. 3. Sharps bins should be dated and signed on commencement of use. 4. There should be regular checks of all stocks to ensure that they are not out of date. Good practice There was a specialist team in Shrewsbury for young people under 18 with substance use
West Mercia Summary - 2009 HMIC Inspection Report (HMIP and HMIC 2009b): The lack of
formal arrangements of any kind for the provision of healthcare in custody were of clear
concern to the Inspection Team. Medication was often out of date and unrecorded and the
quality and cleanliness of clinical suites was variable. The recommendations reflect these
concerns.
3. An Overview of Warwickshire and West Mercia Police Force
In June 2011, the Chief Constables of Warwickshire Police and West Mercia Police and their
respective Police Authority’s committed the two forces to delivering all policing services in
alliance, with the vision: “Warwickshire and West Mercia will, together, deliver high quality
‘value for money’ policing services to protect our communities from harm”. The benefits of
the alliance are:
• Unique cost reductions only possible in an Alliance • More efficient service delivery to communities • Increase operational and organisational resilience • Higher proportion of our people directly delivering services to the public • A single approach to achieve the required cost reductions • Stronger combination of skills and experience
The alliance is not a merger and each force retains its own identity, Police & Crime
Commissioners, Chief Constables and Deputy Chief Constables. The responsibility for the
operational management of SARC remains within each individual force.
Force identities will also be retained, as will separate governance and accountability
arrangements, policing budgets, assets and financial accounting arrangements.
Warwickshire & West Mercia Police share demographic, geographic and environmental
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similarities although there is a significant variation in size between the two forces.
West Mercia Police are organised around five policing areas which cover the counties of:
• Herefordshire
• North Worcestershire (covering Kidderminster, Bromsgrove and Redditch)
• Shropshire
• South Worcestershire (covering Worcester, Malvern, Droitwich, Pershore and
Evesham)
• Telford & Wrekin
Warwickshire Police are organised around the district/boroughs of:
• North Warwickshire
• Nuneaton
• Rugby
• Kenilworth and Southam
• Warwick and Leamington
• Stratford-on-Avon
Both force areas cover diverse urban / rural areas and together include motorway road
networks (M5, M6, M40, M42, M45, M50, M54 and M69) that serve the adjacent major city
conurbations and through traffic.
Together the two forces serve a combined population of 1.7million residents within a 3,630
square mile area, one of the largest policing areas in England and Wales. Whilst the area
has large urban areas, namely Hereford, Leamington Spa, Warwick, Nuneaton, Bedworth,
Redditch, Rugby, Shrewsbury, Stratford Upon Avon, Telford, and Worcester, and a number
of smaller towns, the region is predominantly rural, with some areas, particularly
Herefordshire and Shropshire, deemed ‘sparse’ in population terms.
The overall area is perceived as relatively prosperous, but the urban areas of Hereford,
Kidderminster, Leamington Spa, Leominster, Nuneaton, Bedworth, Oswestry, Redditch,
Ross-on-Wye, Rugby, Shrewsbury, Telford and Worcester all have pockets of deprivation.
Custody In custody the emphasis is on fair and equitable treatment. To offer care to all detained
persons, according to their individual needs, within a functional and safe environment and to
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reassure the public that all staff operating within custody are exercising their powers fairly,
ethically, consistently and in line with relevant legislation. The approximate number of
Detainees in West Mercia Police 2011/12 was 27,827 of which approximately 11962
required medical care and / or forensic services. The approximate number of Detainees in
Warwickshire Police 2011/12 was 10,000 of which approximately 2268 required medical
care and / or forensic services.
Sexual Assault Referral Centre (SARC) The purpose of the SARC is to provide high quality sexual assault services for adults and
children, who primarily are Victims of serious sexual assault. This includes provision of acute
health care and support, forensic medical examination and support to access a range of
follow up or aftercare services.
Each SARC has a SARC Manager who has overall responsibility for care and quality
standards within the SARC. The Contractor will be required to work in partnership with the
SARC staff to ensure adherence to these standards however, the provision of the forensic
medical service to the SARC will remain under the governance of Warwickshire & West
Mercia Police as set out in the tender documents.
West Mercia Police
The geographical area of the force covers Worcestershire, Herefordshire and Shropshire
and Telford & Wrekin and employs around 4200 staff at approximately 100 sites. West
Mercia is currently spilt up into 5 Territorial Policing Units (TPU’s), Herefordshire;
Shropshire; Telford & Wrekin; South Worcestershire and North Worcestershire.
Custody Sites
There are eight designated custody suites: Worcester; Hereford; Shrewsbury; Telford;
Kidderminster and Redditch. The suites based at Wellington and Leominster custody suites
are not generally operational; they are equipped but not staffed, only being used to provide
additional capacity in exceptional circumstances when operationally required.
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Table 1 Travelling times between the key West Mercia Custody Suites
Travelling times
Hereford Redditch Telford Shrewsbury Worcester Kidderminster
Hereford
49 miles 65 mins
65 miles 71 mins
54 miles 70 mins
27 miles 41 mins
41 miles 57 mins
Redditch
49 miles 65 mins
51 miles 52 mins
53 miles 66 mins
25 miles 34 mins
19 miles 32 mins
Telford
65 miles 71 mins
51 miles 52 mins
16 miles 22 mins
41 miles 56 mins
26 miles 37 mins
Shrewsbury
54 miles 70 mins
53 miles 66 mins
16 miles 22 mins
50 miles 70 mins
35 miles 50 mins
Worcester
27 miles 41 mins
25 miles 34 mins
41 miles 56 mins
50 miles 70 mins
16 miles 27 mins
Kidderminster
41 miles 57 mins
19 miles 32 mins
26 miles 37 mins
35 miles 50 mins
16 miles 27 mins
Warwickshire Police
The geographical area of the force covers Nuneaton, Leamington Spa and Rugby and
employs around 1,800 staff at approximately 25 sites. Warwickshire is currently split up into
North Warwickshire and South Warwickshire policing areas.
Custody Sites
There are three designated custody suites: Leamington Spa, Nuneaton and Rugby. Rugby
custody suite is for contingency purposes only.
Table 2 Travelling times between the key Warwickshire Custody Suites
Travelling Times Nuneaton Rugby Leamington Spa Nuneaton
19 miles 27 mins
23 miles 33 mins
Rugby
19 miles 27 mins
20 miles 37 mins
Leamington Spa
23 miles 33 mins
20 miles 37 mins
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Table 3 Local demographic data for Warwickshire & West Mercia Police areas
Worcs Herefordshire Shropshire Telford & Wrekin Warks UK figures
Population figures 557,400 179,300 293,400 162,600 536,000 60,462,000
In employment 28,3600 86,400 137,600 74,900 259,900
% v UK 77.9% 76.4% 74.6% 62.0% 74.8% 70.2%
Unemployed 15,300 4,900 11,900 7,100 17,700
% v UK 5.4% 5.6% 8.0% 8.6% 6.4% 8.1%
Deprivation 44,907 9,048 5,751 34,587 22,977
% v UK 8.2% 5.1% 2.0% 21.4% 4.4% 19.9%
Children in Proverty 17,060 4,930 7,540 9,305 14,760
% v UK 14.5% 13.6% 12.8% 21.4% 13.2% 20.9%
Life Expectancy:
Male 78 79 79 77 78
Female 82 83 82 82 82
GCSE (5A* -C incl Math/English) 3,326 1,077 1,897 1,196 3,607
% v UK 54.7% 56.0% 57.8% 55.9% 58.8% 55.3%
No Qualifications 42,200 19,400 14,300 11,300 42,000
% v UK 12.2% 18.6% 8.2% 10.8% 12.7% 10.6%
Violent Crime Cases 6,926 2,175 2,618 2,139 5,302
% v UK 12.5% 12.1% 9.0% 13.2% 9.9% 15.8%
Hospital stays relating to:
Self Harming 1,220 245 379 371 596
Alcohol 11,446 3,404 4,427 2,460 10,473
Drugs Misuse 2,757 879 1405 943 2,255
% v UK 7.7% 7.8% 7.7% 8.8% 6.4% 9.4%
Smokers related deaths 860 316 527 261 781
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4. Staff Interviews with Police and Health Providers
Approximately 34 interviews (for a full list of those interviewed see Appendix 1) were
undertaken with a range of police and healthcare staff across the area. Themes arose
concerning the following topics:
Response times Issues concerning the ability of the new provider ‘Primecare’ to send staff to deal promptly
with health issues of detainees, were cited by staff in all custody suites across both West
Mercia and Warwickshire. There was some acceptance that these were “early days” for the
new contract but a general feeling expressed that the fundamental issues of lack of staff
resource to fulfil the contract and geography made it unlikely that the problems would be
resolved in the short to medium term.
There were numerous examples cited:
“There only seems to be one doctor on call for whole of Warwickshire”.
“Most issues can wait, but if you get a drunk driver in and it takes doctor three hours to
arrive, by the time he takes a blood sample they can be under the limit. We can have
several people waiting to see the doctor. Staffing and geography is a major issue”.
“The doctor not being there has a knock on for everything else. A few more ambulances
have been called than normal recently just because it has taken so long for the doctor to get
there.”
“A couple of times when phoned for a doctor and two hours later had not heard anything so
rang back – they had not sent anyone because they couldn’t find a doctor so were waiting
for them to changeover and police were waiting for swabs to be taken because of a serious
sexual offence. This was in the interim period when the contract came in”.
“There are a lot of teething issues with regards to getting them there - some travelling a
considerable distance”.
“The call centre don’t always understand the geography and as a result we experience
delays waiting for staff to attend. In a perfect world nurses would be based here with a
doctor on-call as it is too big a geographical area and the resources are too stretched”.
“Under the new contract Primecare are supposed to have a bank of ‘zero hours’ staff which
are available across the West Midlands but occasionally still only one doctor on call.”
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We were told by a number of staff that PACE does not allow for the extension of custody on
medical grounds and so any delays by medical and nursing staff in relation to procedures
such as ‘fitness to be interviewed’ can potentially significantly impact on the investigative
window.
There was some reported variability in attendance of healthcare professionals across the
force areas, and it was suggested that some stations could be disadvantaged if the on-call
Healthcare Professional (HCP) come on duty elsewhere, as their time can be taken up at the
home site. That is, they may pick up additional referrals whilst on-site – one HCP interviewed
stated that she attended one site to “see one detainee but ended up seeing five”. Although
this seemed to some extent to be down to the attitude of the individual HCP, as there were
examples cited by custody staff of HCPs leaving a station to attend another location, even if
there are other detainees that require treatment in the same station. This clearly placed a
strain on the nurses and custody teams who felt that the performance targets were getting in
the way of delivering care. Extended waits for medical staff were often experienced and it
was felt that having just one doctor on duty for the force area was inadequate. It was
reported that there have been instances of doctors not attending their first appointment on
time, with knock-on effects on waiting times.
Staff in the Worcester reported that the nurses would often send detainees to the local
hospital A&E department because they were aware that they would not be able to get a
doctor to attend custody for 3-4 hours despite the known delays at A&E.
The extent to which these instances are representative of the overall service response is not
known, as the performance reports for the new contract were not examined and the service
only began in September 2013. However, given the extent of dissatisfaction at all sites
visited, it is clearly an issue that needs to be carefully monitored and if performance fails to
meets the performance targets as set out in the contract (see below) then fundamental
questions need to be asked of the provider as to whether there are sufficient staff resources
to meet the contract requirement.
Recommendation 1: There should be close monitoring of response times by the commissioner as it is likely response times are not being met.
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Call Priorities and Response Targets
4.6. Warwickshire & West Mercia Police have categorised the expected response times
into five grades. Any service model will need to ensure that the following expected
response times are achieved. The response time will commence from the time of the
initial call for service.
Grade Type Description Response Time
Grade 1 Priority HCP is required to attend for evidential purposes, i.e. requirement for blood samples under the Road Traffic Act, or where the OIC is of the opinion the Detainee needs urgent medical attention.
(The need for HCP to attend urgently under this grade 1 response for medical issues may be quite rare as any requirement for urgent medical treatment would normally be referred direct to the local A&E).
within 60 minutes
Grade 2 Standard HCP is required to attend for routine examinations in relation to drug withdrawal, fitness to be detained or interviewed, requests in line with safer detention protocol i.e. return from hospital, any Detainee on constant supervision etc, all other general requests.
within 60 minutes
Grade 3 Scheduled HCP is required to attend by arrangement with the OIC.
By agreement with the OIC
Grade 4 Advice only Following discussion with the OIC, telephone advice is given. No attendance required.
within 20 minutes
Grade 5 Victim (SARC) A FME is required to attend for a forensic medical examination in relation to a Victim primarily of rape or serious sexual offence. This response time is post assessment of the victim by the Crisis Worker
within 60 minutes
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Most staff stated they were unaware of what was in the contract with the new provider,
although a number said they believed the target to be 60 minutes. However one member of
custody staff thought that “doctors should attend within an hour and a half”.
There were mixed feelings about the previous system of individual FME contracts. Some
staff believed this to be much better in terms of response times, with one members of staff
stating “used to have own doctors (FMEs) and when called them would be out within 10-15
minutes, but now finding that it can take several hours for a doctor to arrive”. Whereas
another interviewee believed that “under old system ..(it) would depend on which doctor was
called, some would try and deal with it over the phone and others want to know the ins and
outs of the situation and then refuse to come out for that.” One interviewee also stated
“there have been some issues in terms of some of the old GPs have moved across to the
Prime Care contract and may have taken some of their old ways with them so they are
taking a little while to get up to speed”.
There was a general feeling of dissatisfaction with the new call centre:
“Call centre not passing on calls promptly. One nurse received notification of a call an hour
after it was made”.
“Control room haven’t got a clue. Send nurse when a doctor is required.
“Very unprofessional, the background noise sounded like a party was going on”.
“Call centre don’t understand the geography”.
It is not known whether satisfaction with and the performance of the call centre is monitored
as part of the contract but this should be included. The contract states in section 4.13, that
“the Contractor will ensure that all calls to and from this number are recorded and held in
accordance with the Data Protection Act 1998 and the recordings kept for 12 months. Staff
should be made aware of this provision and specific incidents, such as the reported
“unprofessional behaviour” investigated as part of contract monitoring.
Recommendation: Custody staff should be aware that any unprofessional behaviour on the part of call centre staff should be logged and reported.
Most custody staff interviewed believed that “in an ideal world”, custody suites would be
staffed by a nurse on-site, with on call medical cover, as this would resolve the majority of
problems relating to response times. Such a model could be investigated for future
26
contracts, as happens with other forces but would require nurses/healthcare practitioners to
be able to undertake a greater variety of tasks (see below – roles and responsibilities). Recommendation 2: It is strongly recommended that in any other future contract negotiations the role of the nurse, with extended skills, working on site, should be investigated.
Culture and relationships All custody staff interviewed showed a very positive attitude towards providing a safe place
of custody and took their responsibilities to provide ‘care in custody’ seriously.
Relationships between the police and local A&E departments were reportedly as generally
poor, although the exception seems to be between police and staff in Worcester Hospital.
Police staff stated that they often spent 4 or 5 hours waiting in A+E for a detainee to be
assessed and treated, which this ties up two officers. On “rare occasions in the past” police
staff with a detainee would be seen quickly to allow them to return the detainee to custody
and for police return to their operational duties but in general there it is uncommon for
exceptions to be made for the police even when escorting an abusive and disruptive
detainee.
Custody staff stated that it was far from unusual for suspects to be bailed or ‘no further
action’ taken whilst attending A+E for operational reasons (staff pressures) even, in some
instances, before investigations into the offence had taken place. Although it was stressed
that this would only happen for minor offences.
There was no evidence of the existence of joint-working protocols between A&E
departments and the police, although we understand that some discussions are happening
locally in areas such as North Worcestershire. Custody staff felt this would be helpful and
should cover all custody suites/hospitals across the joint force areas
Recommendation 3: Joint-protocols between the police and A&E Departments should be discussed.
There is no link between HCPs and NHS Primary Care, no access to primary care
information systems and no clear referral pathway from custody to the community. It would
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be of benefit to clarify the care pathway for detainees to and from primary care and set out
the processes and procedures to support this.
Recommendation 4: Greater clarity is required about primary care pathways once the detainee leaves custody and the role of Primecare in communicating with primary care agencies.
There is apparently an agreement in Worcestershire that all detainees on discharge from
A+E should have a discharge form completed, setting out what treatment has been given to
the detainee in the department. However, completion rates are generally poor resulting in
HCPs having to follow-up by request this information by fax and even requesting that officers
return to A&E to either collect the form or get it completed. This agreement should be
reviewed between agencies and the content disseminated to all NHS and police staff to
ensure it is adhered to in future. This practice should also be implemented across all areas
in West Mercia and Warwickshire.
Recommendation 5: Alongside, Recommendation 3 above, the routine completion of a discharge summary should be completed at all times.
Given the newness of the existing contract it was not possible within the timeframe of the
review to determine whether the new provider had a clear set of policies that stipulate when
a detainee should attend A&E. This should be reviewed between the provider and the police
because more treatment could potentially be provided in custody (as happens in other
forces), thus reducing the burden on the police and the NHS. Ensuring that only those
patients who need to visit A&E are taken under an agreed protocol would have measureable
clinical and financial benefits across all organisations.
Recommendation 6: There should be an agreed understanding between the police and Primecare of the nature of healthcare that should be provided in custody rather than A&E. Roles, responsibilities and policies
A health risk assessment is completed by custody staff at the custody desk, a care plan is
initiated, checked with the supervisor and entered onto the ‘NSPIS’ system. It was reported
that where custody staff suspected that the detainee found it difficult to talk about sensitive
28
health issues, they were always asked or offered if they would prefer to be interviewed in a
more private environment, such as a separate interview room.
The guidelines by the provider on the role of the FME and Custody nurse (for West Mercia)
are not well known to known to police custody staff and this has led to some confusion over
roles and responsibilities and the suggestion that in many instances, doctors are called out
when a nurse could carry out the procedure. This should be clarified for staff in the West
Mercia force area where both nurses and doctors carry out the contract.
Recommendation 7: Custody sergeants need more specific guidance on the roles of medical and nursing staff. It was reported that medical staff covering the West Mercia force area, are often reluctant to
‘multi-task’ (e.g. undertake routine procedures that would normally be carried out by a
nurse), with consequent delays in getting detainees treated. This needs to be clarified with
the provider and instances reported to the contract monitoring team.
Recommendation 8: There should be a log kept of the times that Doctors refuse to attend for routine procedures. The HNA team were informed that it is a provider policy that only doctors can dispense
methadone, which can lead to delays because of the previously described response times
for medical staff. This approach seems outdated and unnecessary, as, under the 2012
revisions to PACE (1984), the administration of methadone in custody is the responsibility of
the relevant custody healthcare professional, which can be either a forensic medical
examiner (FME) or custody care practitioner (CCP). Given the changes to PACE it would
seem appropriate that the policy is reviewed by the provider to allow administration of
methadone by nurses
Recommendation 9: The commissioners should persuade Primecare to re-consider their policy for the prescription and administration of methadone
The treatment of head injuries, was a frequently occurring problem in all sites and a
significant drain on staff resources, as it requires two officers to escort the detainee to the
A+E department (see above on ‘response times’). Custody staff were of the opinion that any
head injury, however minor, required the police to take the detainee to hospital. Some staff
stated that this was a requirement set out in the ACPO ‘Guidance on the safer detention and
29
handling of persons in police custody’. However, in relation to the former, the guidance
states “when dealing with a detainee who is exhibiting symptoms of a head injury”, which
suggests that hospital attendance is not necessarily required in all cases. The guidance
should be reviewed between the police and the provider and clear guidance developed for
custody and healthcare staff to follow in relation to the treatment and management of head
injuries.
This discussion should take place as part of Recommendation 6 above
Under the new contract, detainee medication is ‘bagged’ by the FME and can then be
administered by detention officers. However, whilst this approach was thought sensible by
some custody inspectors and sergeants a number of detention officers were uncomfortable
about administering medication without any basic training on drugs and their side effects.
Recommendation 10: Detention Officers should be provided with basic training in the administration of medication. Mental Health The approach to dealing with the mental health issues of detainees was very different across
the two force areas. Warwickshire has well established ‘Liaison and Diversion’ services,
which operate from both custody suites and has been previously summarised by IHWUK for
Health and Justice (West Midlands), NHS England2
as follows:
Name Main Location Active locations
Summary Information
Warwickshire Criminal Justice Mental Health Liaison Service (CJMHLS)
South Warwickshire: Yew Tree House, 87 Radford Road Leamington Spa CV31 1JQ And North Warwickshire: Riversley Clinic, Clinic
Warwickshire Justice Centre, Vicarage Street, Nuneaton, Warwickshire, CV11 4JU And Warwickshire Justice Centre, Newbold Terrace, Leamington
Focus: Liaison and Diversion across the CJS. Including input to high risk cases managed through MAPPA and probation
Area covered: The service is funded for and available 7.00am to 3.00pm in South Warwickshire (Leamington Spa) and 8.00am to 4.00pm in North Warwickshire (Nuneaton), Monday to Friday and some cover for Rugby. Outside these hours there is no dedicated mental health assessment
2 Map of Mental Health Liaison and Diversion Schemes 2013/14, unpublished report for NHS England, Health and Justice (West Midlands)
30
Drive, Coton End, Nuneaton, CV11 5TY
Spa, Warwickshire, CV32 4EL
service available to the criminal justice system.
Provider: Coventry & Warwickshire Partnership Trust Commissioners: Arden Commissioning Support Unit, on behalf of North Warwickshire, South Warwickshire and Coventry and Rugby CCGs + Probation Trust + Warwickshire Police Contract Term: Annually negotiated Contract price: £144k (South Warwickshire CCG & Warwickshire North CCG contribute £42k, Probation £38k and Police £23k Also received a ‘one-off’ payment of £10k from DH for being a ‘Pathfinder’ Project Lead: Vicky Hancock Service Manager/Clinical Lead Coventry and Warwickshire Partnership Trust Swanswell Point, Stoney Stanton Road, Coventry CV1 4FH [email protected] Tel: 024 7696 1242 Mob: 07876 651555 Staffing: 2 Full-time FCPNs
The schemes were highly valued by custody staff who felt that they provided good cover and
were a valuable asset during office hours, assessing detainees and liaising with crisis and
secondary MH teams as appropriate. However, custody staff in Warwickshire still experience
difficulties in dealing with the mental health problems of detainees out of hours. According to
staff, under the old FME system all doctors on the rota were section 12 approved and had a
good working knowledge of local mental health systems, whereas under the new contract
not all visiting FME are. This has led to poor joint working with mainstream MH services (out
of hours), little sharing of information and police staff having to co-ordinate MHA
assessments. Section 6.6 of the contract with Primecare states “The Contractor will ensure
that all Forensic Medical Examiners and HCP’s will as a minimum: Be qualified and
registered medical practitioners who have additional competences and qualifications, such
31
as Section 12 Approval under the Mental Health ACT 1983, which will enable the individual
to undertake formal Mental Health Assessments”. It would seem reasonable under these
circumstances to request that the contractor undertake an audit of existing FME staff to
determine how many are section 12 approved and what steps they will take to address any
shortfalls.
Recommendation 11: Primecare should undertake an audit of the number of its FMEs that are Section 12 approved and accordingly inform the commissioners.
Despite the very positive view held of the ‘Liaison and Diversion’ service, as identified in the
report mentioned above, there are a number of areas identified locally for further
development:
• Services currently stretched too thinly because of lack of capacity – under resourced because of having only two Forensic CPNs. Need to bolster existing schemes (they are in the right places).
• Need to provide 24hr and weekend cover • Need specialist input to manage clients with Learning Disability and Autism and
Aspergers’ Syndrome
Also, it was identified that probation funding may be under threat in 2014/15 due to the
proposed organisational changes, which may require additional ‘health’ resources being
invested to keep the service at current capacity. Given the value placed on the service by
police staff, the future of the service should reviewed in relation to the healthcare contract for
police custody post 2015.
Recommendation 12: The current funding basis for the Liaison and Diversion service should be reviewed.
West Mercia does not have ‘Liaison and Diversion’ services across its custody suites. As the
previous report identified, there is one scheme in operation but this deals principally with
detainees with Learning Difficulties – as summarised below:
Worcestershire Liaison and Diversion Service: Criminal Justice Care Pathway
Wyre Forest Community Learning Disability Team Adult & Community Services Worcestershire County Council
Worcester Combined Court Worcester Magistrates' Court Worcester Custody Suite
Focus: To co-ordinate all agencies within the Criminal Justice System with Health, the Local Authority and Third Sector Services to develop individual plans to provide appropriate support and treatment to reduce offending, and manage risks in people with Learning Disabilities who offend.
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PO Box 5118 Kidderminster DY10 1YT (Shortly to move location to Kidderminster Library)
Redditch Custody Suite
For those when the Criminal Justice route is required: to provide appropriate care and support. Area covered: Currently, predominantly the Wyre Forest area of Worcestershire where a pilot scheme is in operation. The scheme is shortly to be extended to the other areas of Worcestershire i.e. Bromsgrove/Redditch, Droitwich & Wychavon, Worcester & Malvern. Provider: Worcestershire Health & Care NHS Trust in partnership with Worcestershire County Council. Commissioners: Worcester Joint Commissioning Unit (Worcester County Council and South Worcester, Redditch and Bromsgrove and Wyre Forest CCGs) Contract Term: Rolling block contract with Trust Contract price: Not individually costed with block contract Project Leads: Lizanne Jones Lead Psychologist for Worcestershire (Learning Disabilities) Worcestershire Health and Care NHS Trust The Robertson Centre, Kidderminster Hospital, Bewdley Road, Kidderminster, Worcs DY11 6RL Tel: 01562 513 290 Email: [email protected] Staffing: Members of the Wyre Forest Community Team for Learning Disabilities (includes input from psychologists, community nurses, social workers, speech & language therapists, psychiatrists, occupational therapists and physiotherapists). Staff carry out the function of the Care Pathway as an integral part of team working.
33
Whilst this summary suggests that “the scheme is shortly to be extended to the other areas
of Worcestershire i.e. Bromsgrove/Redditch, Droitwich & Wychavon, Worcester & Malvern”,
it is not know whether these plans have been put in place. One custody inspector
commented that the scheme works well in the Wyre Forrest but not elsewhere. Also it is not
know whether discussions have extended to the introduction of MH Liaison and Diversion
schemes across the West Mercia region. The recommendations for the above mapping
project should be reviewed in relation to the healthcare contract for police custody post
2015:
• (Worcestershire) Have developed a good model care pathway but only delivering ‘bits of it’ at present and the extent of which is not known – need to do more detailed mapping locally
• Need to build on the services delivered by the Learning Disability service to increase the amount of Mental Health input
• Need a rapid response service within custody suites • Problem establishing services because of limited short-term funding
Recommendation 13: Funding for a Liaison and Diversion team for West Mercia should be identified as there is a pressing need for a rapid response service within custody.
New protocols have been put in place in both police areas for dealing with detainees who
have been detained under Section 136 of the Mental Health Act. In both areas, this has
been viewed generally positively and custody staff feel that it is an improvement from
previous arrangements whereby detainees automatically came into police custody.
In Warwickshire police now have access to the Caludon Centre in Coventry under a multi
agency agreement where 136 arrests are taken directly by ambulance rather than to custody
suites. However, there was problem identified with capacity at the centre as it only has one
bed, so there are occasions when the police have to consider whether to take them into
custody or another place of safety, although these incidents happen infrequently.
Another problem area for the police in Warwickshire in relation to the Caludon Centre is that
they refuse to see clients who are either intoxicated or violent and it was suggested by
custody staff that the interpretation of this was highly subjective. It would be helpful if the
issue of ‘risk assessment’ with regard to the use of the S136 suite was reviewed in the light
of these findings and guidance issued to both police and NHS staff. In another police area
who experienced similar issues, a joint initiative between NHS and the police resulted in an
acceptance that only an ‘unmanageable’ level of risk (violence or intoxication) would indicate
34
the need for continuing police detention and this would be jointly assessed by the police and
NHS staff. A similar joint protocol is recommended for both Warwickshire and West Mercia
force areas.
Recommendation 14: A protocol, between the Police and the Mental Health Trust, should be developed with specifies the level of unmanageable risk that the Section 136 suite should accept.
Despite generally improved MH services in Warwickshire, mental health is still viewed as a
“massive time-consuming issue and there is often no answer”. Safer Neighbourhood Team
used to have a “local bobby per village but now have a local bobby who covers a number of
small towns and villages”. “The CPN is reactive so covers a 200 mile area, so will see a lot
of the same people repeatedly but sometimes will not get out in the community at all if stuck
in custody”.
It was thought by police that there are “many more mental health related incidents now than
we used to have, which they believe is a national problem and that “police have to pick up
health and social care issues that aren’t really their responsibility”.
It was felt that ‘Frequent Flyers’ should be picked by some form of review system to and that
“it doesn’t get picked up now in the way it used to. Individual officers in each area were PVP
(Protective Vulnerable People) officers and they would trawl through these cases. There is
still a PVP department for more domestic related incidents and vulnerable children”. Partner
agencies (police, NHS Trust, Primecare) should consider developing a system of identifying
and developing multi-agency plans of care for those detainees with mental health problems
who frequently come through custody or to the attention of the police generally.
Warwickshire has a Multi Agency Mental Health meeting either bi-monthly or quarterly at
which mental health cases and issues are reviewed. This would seem to be the appropriate
forum for considering such a proposal.
Recommendation 15: There should be multi-agency agreement reached on alternative disposals for those with a mental health problem who are frequently arrested.
In Worcestershire there is an individual in post who acts as co-ordinator for Approved Mental
Health Professional (AMHP) input in Worcestershire (e.g. MHA assessments) and Lead for
S136 for the Trust and manages the psychiatric assessment team – therefore responsible
for mental health services for people in custody across the sites of Kidderminster, Redditch
and Worcester.
35
There is a county wide rota for the AMHP service and there are around 40 in total who are
utilised across the county. It is difficult to predict volume/demand but the AMHP service
usually sees around 4 per day.
The Psychiatric Assessment Team have four on duty during office hours and 2 out of hours.
As identified above, there is no mental health ‘Liaison and Diversion’ scheme. It was stated
that there used to be one in Telford and one in Hereford but these were discontinued.
However it was suggested that “it would be good to have one”.
The Trust are developing a ‘single point of access’ – “there is one in each area at the
moment”.
Generally, as in Warwickshire, arrangements for dealing with individuals detained under
section 136 in West Mercia were generally thought to be adequate. “There are 3 or 4 centres
across West Mercia and all agencies are thinking about other ways of dealing with these
cases rather than taking them into custody”.
As with Warwickshire, Worcestershire now has a new section 136 protocol – see
S136 Protocol Worcestershire
There is a S136 suite in Worcester and under the protocol detainees with MH problems
should go directly to the S136 suite rather than into custody unless under the influence of
drink, drugs or are violent. However, similar problems exist in relation to the interpretation of
these terms and as mentioned above, it would be worth reviewing the protocol with a view to
developing guidance for a joint ‘risk assessment’.
There are no beds but 3 examinations rooms – “a recent CQC inspection suggested they
should have a bed”.
There is also a S136 monitoring group for Worcestershire, which has been running for about
18 months, where issues can be addressed between the police and the AMHPs. It was
reported that recent data on use of S136 shows that 87% of detainees have gone to the
suite and they average around 20 a month for the county.
Mental Health services have also been seen to have improved in Shropshire over the last 12
months with the opening of the ‘Redwood Centre’ S136 suite by South Staffordshire and
36
Shropshire Healthcare NHS Foundation Trust, which is the new, purpose-built inpatient
mental health facility for Shropshire.
In terms of future contracting of healthcare provision across both Warwickshire and West
Mercia areas from 2015 onwards, it would be advisable to gather and review all section 136
protocols, covering all counties, with a view to establishing a consistent and equitable
approach across both force areas, with perhaps one over-arching joint strategic board/board
to oversee and monitor plans and development.
Recommendation 16: There should be a pan-county review of Section 136 protocols in advance of the next commissioning round for healthcare in custody in 2015.
Notwithstanding, the broadly held view that mental health services had generally improved in
West Mercia there still a number of issues that were of concern to both police and NHS staff:
• It was stated that sometimes it is “difficult getting a bed within acute units” largely as
a consequence of hospital/bed closures
• “FMEs have to cover a large patch and are spread thin. The AMHP can use own S12
approved doctors but this can cause tensions with the FME”.
• “FMEs don’t always liaise with Mental Health Services when detainees are known to
services. The AMHP should be the first point of contact”.
• “Primecare to do the initial assessment and refer detainees to the crisis team but it
can be a couple of hours before they are seen”.
• “S136 suite won’t have them even if they have had a small amount of drink” and
“officers are reluctant to take detainees there as they can be stuck for hours”.
• “Getting a mental health assessment usually takes a day to co-ordinate with one
AMHP covering all of Telford and Wrekin”
• “People are actually released back into the community when they should not be as a
result of there being no beds available”.
• “If arrested for ‘Breach of the Peace” because the person was not in a public place
(i.e. can’t use S136) then difficult to get the person assessed”.
• “There is no protocol for dealing with people who have a Learning Difficulty or
Asperger’s”
• “Getting Emergency Duty Team to attend can be a major problem”.
• Police after care plans are seen to be “not actioned by partners”.
37
Given these on-going issues, and the potential impact on detainees, custody staff and
general policing, it is recommended that partners develop an improvement plan for MH
services, overseen by a strategic board or group (as above) and this also addresses
Learning Disability, Asperger’s and Autistic Spectrum Disorders.
Recommendation 17: Given the issues outlined above a mental health improvement plan should be developed which also addresses learning disability, asperger's and autistic spectrum disorders,
Drugs and alcohol
The Drug Intervention Programme (DIP) seems to be generally working well in all areas, with
DIP workers either based at or making regular routine visits to custody suites.
Under the Criminal Justice and Court Services Act 2000, the police have the power to drug
test detainees aged 18 or over who have been charged with a 'trigger offence' (these include
theft, burglary, robbery, and possession and supply of Class A drugs) these powers are not
used in the Warwickshire force but are in West Mercia. However, it was suggested that ‘test
on arrest’ in West Mercia did not result in many new referrals as most individuals were know
to services.
DIP workers generally conduct a sweep of the cells in the mornings and receive referrals
from custody staff if the risk assessment identifies a substance misuse problem. All
detainees who test positive for specified Class A drugs (heroin and/or cocaine/crack) are
seen unless they refuse. It has suggested, however, that this approach to drug testing
misses a lot of other substances (e.g. cannabis, ecstasy, hallucinogens) that are more
frequently used — given that heroin use is in decline nationally — and misses those who are
“treatment and DIP naive”.
A key priority was ensuring that detainees have access to ongoing care in the community
and there would appear to be good referral pathways into community services.
In Worcestershire, it was stated that Drug intervention workers staff have “very large”
caseloads as staff are not replaced....we used to have caseloads of around 40 but now have
caseloads of 60 – 70”. This seems at face value to be excessive and it was said as a
consequence, they only see clients on a 1-2-1 if necessary and more is done by group work.
There is a welcome group for clients who have been picked up through custody and the
service will “chase people up” if they don’t attend. Another problem identified in
38
Worcestershire is that clients tend to stay with CJS workers as there are no
resources/capacity to move them on. It is recommended that the relevant Local Authorities
together with NHS England, consider a uniform approach to the commissioning and delivery
of DIP services across Warwickshire and West Mercia, taking into consideration issues of
caseload size and models of intervention (i.e. group v individual work) that best promote
recovery outcomes and value for money.
Recommendation 18: It is recommended that the relevant Local Authorities together with NHS England, consider a uniform approach to the commissioning and delivery of DIP services across Warwickshire and West Mercia, taking into consideration issues of caseload size and models of intervention (i.e. group v individual work) that best promote recovery outcomes and value for money.
Interaction with Metal Health services was seen to be a problem in a number of areas. It was
suggested that some clients with MH problems use drugs and/or alcohol to self-medicate.
Drug workers stated that often mental health services “won’t take on clients if still using
alcohol and drugs and there is no protocol in place to manage ‘dual diagnoses’”. It is
recommended that protocols on the management of detainees with dual diagnosis are
agreed for each custody suite between all partner agencies.
Recommendation 19: Protocols on the management of detainees with dual diagnosis are should be agreed for each custody suite between all partner agencies.
Another problem identified in Worcestershire was that of ‘data collection’, which was seen as
a problem for a number of reasons; there is “lots of paperwork”, which means that the
“quality of service is often rushed due to time limitations; notes have to be inputted on
‘HALO’ (Case Management System) but paper notes still have to be completed. It would be
good to have a tablet device so that we could input the data whilst seeing the clients”.
Few referrals to the DIP service have come via Primecare staff in any of the sites, although it
was recognised that the contract has not been in place long.
More could perhaps be done to promote ‘recovery’ with leaflets and posters on display in
custody areas. It was good practice that these were immediately evident in a number of the
custody areas visited.
39
Recommendation 20: Guidelines should be in place for Primecare staff to refer on to DIP services and data relating to the number of referrals should be captured and monitored, also, leaflets and posters promoting ‘‘recovery’ services should be on display in all custody areas. Communication and IT The NSPIS custody software is used to record health data, which includes the assessment,
care plan and health-markers or flags (e.g. previous self-harm, HIV etc). This was seen as
“pretty useful” and “generally works well”. NSPIS is linked to the police national computer
(PNC) so when an individual is linked with a past detention it will pull PNC information
across to the NSPIS record and “identify if there are any warning markers, ailments,
incidents of self-harm or any contagious diseases etc”. “That way even if individual does not
mention something on the risk assessment they will still have the information and
background and ask them about it”. It was suggested that West Mercia are ahead of
Warwickshire in that they have another system called Genie that “links all their crimes
systems and other Intel systems as well. Warwickshire have to do a manual check on any of
the local systems, which is hit and miss as to if it gets done”. It is hoped that Warwickshire
will have access to the ‘Genie’ system in the near future.
There was generally felt to be adequate coverage of CCTV monitored cells in all sites,
although they did differ in the ratio of monitored to non-monitored cells. If a detainee is
thought to be at risk they will be put in a ‘camera cell’ so they can be observed. This is seen
as a useful tool for the unobtrusive monitoring of detainees with health issues, although
there are still occasions where more direct observation is called for “have been times where
someone has been trying to hurt themselves so have to watch at the door, which takes 1 or
2 officers off the street whilst waiting for the doctor to arrive, which can take several hours.
Has a knock on effect”.
It was identified that when the healthcare contract started there was an issue with access to
computers as Primecare staff “couldn’t get on or weren’t too sure what they were doing”.
This issue should be considered for any future contracts where training of new healthcare
staff should be undertaken prior to the start of services if this is possible.
At the end of the second month into the Prime care contract the medical computer system
still does not work. This means that guidelines and best practice information is not available
to the HCP. The paper assessment forms (described as CAF - Common Assessment Form)
40
are completed by the nurse and collected on a weekly basis. The nurse was unaware
whether these records were then subsequently uploaded on to a central system or simply
filed.
When the nurse requires previous clinical information they are required to access the history
captured on the NSPIS system. NSPIS was not designed to replace capturing detailed
clinical information that would be routinely be collected as part of the normal consultation
process. Clinical and custody staff were aware that the lack of information systems was
having an impact on policing matters in addition to patient care. For example, when Medacs
held the contract officers would be given a single sheet of A4 that stated the person was fits
to detainee and charge etc. Custody staff welcomed the simplicity of having a simple report
that gave them direction and confidence to discharge their duties.
Recommendation 21: The commissioners should seek an update report from Primecare on the project to introduce computer systems into custody suites and how police staff will be briefed on its intended use – plus issues around access and data sharing.
Appropriate adults
In West Mercia, there is an Appropriate Adults Service covering Worcester, Kidderminster
and Redditch provided by ‘Onside’, which employs around 30 volunteers on rota with a
response time of within 2 hours operating during office hours.
Referral is generally made via the FME or nurse not the custody team. They aim to ensure
that an appropriate adult arrives at same time as solicitor.
The Juvenile service is fully voluntary and provided by Youth Support Services (YSS). The
length of the call out varies but frequently can last 10-12 hrs. Onside do “step in” at times
when a worker is needed and no volunteer can be found.
There is no dedicated appropriate adult service in Warwickshire and this was identified as a
problem by some custody staff, “we have been trying to get one going in Warwickshire... not
so much an issue with young people, but problem is with adults with learning difficulties who
seem to fall in the middle of nowhere”. “Sometimes have to bail people because cannot get
an appropriate adult, which is unacceptable. We have recently put in a business case for a
paid appropriate adult service, which certainly other local forces use. Finances have not
helped this case”.
41
West Mercia are “looking to expand the service delivered in Worcestershire...(for)
appropriate adults on a voluntary basis” and are also considering an option “to see whether
youth justice service and mental health teams can provide a service based on spot
payments. There is a rota they can use but at a cost.”
Recommendation 22: In line with a number of other forces and best practice, commissioners should consider the commissioning of appropriate adult services to ensure equality of access for young people and vulnerable adults indeed, this is a PACE requirement, and no child or vulnerable adult should be interviewed without an Appropriate Adult.
Training Officers receive basic training on first aid but would welcome more face-to-face training
provided by healthcare professionals to improve their understanding of common health
problems including mental health, physical health (e.g. diabetes, asthma), medication and
substance misuse.
There has also been the recent introduction of an e-learning programme ‘Mental Ill Health &
Learning Disability Awareness programme’ on the National Centre for Applied Learning
Technologies (NCALT) website. NCALT is a collaboration between the College of Policing
and the Metropolitan Police Service, which assists the 43 Home Office police forces in
England and Wales, delivering local and national e-learning via a Managed Learning
Environment (MLE). Despite these developments a number of police staff felt that training
covering other health issues (e.g. medical conditions, drug and alcohol health problems) was
largely non-existent.
It was stated that there was “some healthcare training for Sergeants covered in initial training
but should have top-up training”. It was also identified that there is “a ‘custody portal’ with an
on-line community of custody staff with its own knowledge database and a national custody
email network, which is useful for sharing and disseminating information”.
Recommendation 23: It is recommended that the two police forces consider including the delivery of specific and relevant healthcare training by a qualified provider within any future healthcare contract.
42
Module 2 Data Linkage: FME Involvement with Detainees
Datasets: datasets supplied and processing were:
2) Both West Mercia Police and Warwickshire Police provided two datasets:
a. one containing all detention records for 2012 along with the custody risk assessment; and
b. one containing all detentions which had an FME assessment, along with the response.
3) All custody records from the two forces were merged into a single dataset
covering 2012 and the unique custody detentions were extracted based on
the ‘Custody Record Number’3
i. Of the total detentions, around 4,400 (14%) had no valid postcode
recorded and could therefore not be linked to geography or
deprivation data
. A separate file was constructed to contain
the Custody risk assessment for each detention. Overall there were 31,937 custody detentions. These are not unique individuals since repeat
detentions are all recorded and there is no person identifier.
ii. The final sample with geography/deprivation was 27,527 (86%)
4) All FME records from the two forces were merged into a single dataset
covering 2012 and the unique FME Assessments were extracted based on
the ‘Custody Record Number’.
i. The total sample of detentions with an FME record was 7,919; of
which 6,059 (77%) had a valid postcode.
5) Medacs data – this was provided for just West Mercia Police and for years
2011, 2012 and to March 2013. The unique identifier was in a different
format to the reference in the custody data. Once split and reconciled, this
ID could be linked back to the custody data. Overall N = 8,975; Number
linked to Custody data = 7,348 (82%).
i. Since an individual could be seen for more than one reason by
Medacs , only 4,413 custody detentions were known to have
resulted in being seen by Medacs
3 First the Warwickshire dataset was cleaned to populate the ‘Custody Record number’ for every Risk Assessment relating to that Custody record – as it was supplied with just the initial record completed
43
ii. Of those seen, 3,831 (87%) had a valid postcode recorded and
could therefore be linked to geography or deprivation data
iii. However, of the Medacs sample, only 2,213 (50%) could be linked
to the FME sample from the Police data.
Analysis: The data were manipulated using MS Access and MS Excel for data linkage and
cleaning then analysed using SPSS v20. Descriptive univariate statistics were produced
initially and a multiple logistic regression was used to determine the odds ratio of the
significant factors that predict seeing an FME whilst being held in custody.
Results
1. Overall descriptions of detainees a) Basic demographics
• Over all of 2012, there were around 32,000 detentions at Warwickshire & West
Mercia’s custody suites combined • Of these, 84% were male and 16% female • Only 4,377 (14%) did not have a postcode of residence recorded, and could
therefore not be allocated to a local authority or deprivation quintile • Of detainees with a valid postcode, the majority (51%) lived in the two most deprived
quintiles of areas; only 8% were from the most affluent quintile. • Of these, 85% were residents of Warwickshire & West Mercia. The map below
(Figure 3) shows the wide distribution of residency of all detainees at Warwickshire & West Mercia’s Custody suites.
• Overall, 18,300 (68%) of detainees were aged under 35, with around 4,000 (14%) aged 10-18 and just 1,200 (4%) aged 45+.
These data are summarised below in Figure 1.
44
Figure 1 Demographics of all detainees in custody suites across Warwickshire & West Mercia, 2012 (where postcode is recorded, n = 12,325)
45
Figure 2a Local Authority of residence of all detainees at Warwickshire & West Mercia custody suites during 2012 (with valid postcode, n = 27,527)
46
Figure 2b Local Authority or Police Force of residence of all detainees at Warwickshire &
West Mercia custody suites during 2012 (with valid postcode, n = 27,527)
47
Police Force Count %Not known (no postcode) 4410 14%West Mercia 17347 63%
Bromsgrove 880 3%
Herefordshire 3001 11%
Redditch 1741 6%
Shropshire 3437 12%
Malvern Hi l l s 756 3%
Worcester 2293 8%
Wychavon 1147 4%
Tel ford & Wrekin 2157 8%
Wyre Forest 1935 7%
Warwickshire 6076 22%North Warwickshire 541 2%
Nuneaton & Bedworth 1920 7%
Rugby 1262 5%
Stratford-upon-Avon 821 3%
Warwick 1532 6%
West Midlands 2307 8%Staffordshire 186 1%Metropolitan Police 179 1%Leicestershire 167 1%Gloucestershire 149 1%Northamptonshire 125 0%Thames Valley 103 0%Dyfed-Powys 102 0.4%North Wales 77 0.3%Merseyside 72 0.3%Greater Manchester 56 0.2%Avon & Somerset 55 0.2%South Wales 54 0.2%All other areas (n=24) 472 1.7%
48
For residents of Warwickshire & West Mercia, it was possible to calculate and age-standardised detention rate by local area deprivation. This showed that there were 6.5 times higher rates of detention in the most deprived fifth of areas (75 per 1,000 males and 14 per 1,000 females) compared with the most affluent areas (11 per 1,000 males and 2 per 1,000 females). This is reflected in the rate of detention by Local Authority (as at 2009), where there were 2.6 times higher rates in men and women living in Worcester and Wyre Forest than Strafford-upon-Avon and North Warwickshire. There was a tendency for higher levels of deprivation where detention rates were highest but where this varies, it may be due to poorer data quality.
Figure 3 Age-standardised rates of detention in Warwickshire & West Mercia residents
by a) Index of multiple deprivation and b) Local Authority.
49
2. What is the influence of age? Figure 4 Basic demographics by age of detainees in custody suites across Warwickshire & West Mercia 2012
0%
10%
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50
• The age distribution of detainees did not vary greatly across custody unit or between sexes – although there was a slightly greater proportion of males aged 19-24 than females.
• The most deprived areas were most likely to have detentions of people aged 25-34
than of all older ages. However, patterns by deprivation may be influenced by the relatively smaller number of people who live in the more affluent fifth of areas.
• Those requiring a medical investigation (FME) were more likely in the older age
groups (25+) and those not requiring FME were more likely younger (under 25). • Age did vary by charge; so:
o Theft, criminal damage, public order or drug offences were more likely in
those aged under 25 o Mental health, sexual offences, driving offences and fraud were more likely in
those aged 45+
51
3. What proportion of arrests requires an FME call out and what influences the likelihood of a detainee seeing an FME?
Figure 5 Numbers and proportion of detainees seen by an FME by basic demographics (Custody data records only – not linked to Medacs)
Figure 6 Proportion of detainees seen by an FME by other potential predictors (Custody data records only – not linked to Medacs)
52
• Overall, 25% (7,906 / 31,937) of detainees were seen by an FME (Fig 6)
o Between 200 and 2,250 detainees in each custody suite are seen by an FME
o The proportion of detainees seen by an FME varies considerable across suites,
from less than 5% in Shrewsbury to over a third in Hereford and Worcester.
• This was variable across basic demographics:
o age strongly increased the likelihood of seeing the FME - with those aged 25-44
significantly more likely than those aged under 25 to see a FME and those aged
35-64 significantly the most likely to see the FME.
o There were large differences across custody suites and LA of residence in
likelihood of seeing the FME – detainees at Shrewsbury (predominantly residents
of Shropshire) were significantly least likely to see an FME and those in
Worcester and Hereford significantly most likely to see an FME
o Females were significantly more likely to see the FME than males, although
nearly 6,500 men saw and FME compared with 1,400 women.
• Of other possible predictors:
o There was no statistically significant likelihood of seeing an FME with increased
deprivation.
o However, people of unknown residence (no valid postcode recorded) were
significantly more likely to see the FME than all other detainees.
o People detained under the Mental Health Act were the most likely to be seen by
the FME and those arrested for sexual offences were second most likely.
o People arrested for fraud were least likely to see the FME
o With the exception of detainees deemed capable of understanding, those
answering positively to any the custody risk assessments* were significantly
more likely to be seem by an FME
o Those dependent on alcohol (1,900), injured or unwell (5,250), taking medication
(2,200), likely to self-harm (4,000), dependent on drugs (4,500) or had mental
health problems (6,700) were most likely to be seen by an FME.
* note individuals could be assessed positively to multiple risk assessment questions
53
3a. Are there any differences between those requiring an FME and those that do not?
Figure 7 Distribution of detainees seeing an FME or not by basic demographics (Custody data records only – not linked to Medacs)
• There were very few differences in demographics between detainees who saw the FME and those who didn’t. Those who saw the FME were significantly:
o More likely to be female than male o More likely of unknown residence (no valid postcode recorded) o Less likely to be aged under 25 and more likely to be aged 35-64 o More likely to be detained at Worcester and Hereford and less likely at
Shrewsbury and Nuneaton.
• With regard to crime category, those who saw the FME were significantly: o More likely to have been detained under the Mental Health Act, although 140 of
235 of detentions under this Act did not see an FME o More likely to have been arrested for sexual offences, breach of orders, public
disorder or violence o Less likely to have been arrested for burglary, theft, drug / driving offences and
fraud.
• With regard to positive response to Custody assessment, those who saw the FME were significantly:
o Less likely to be capable of understanding o More likely to state Yes to all other assessment criteria
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54
Figure 8 Distribution of detainees seen by an FME or not by Home Office crime category
Figure 9 Distribution of detainees seen by an FME or not by positive response to
Custody assessment
55
Figure 10 Summary characteristics of whether detainees are seen by the FME - Multiple logistic regression statistics
• When all the variables are entered into a multiple logistic regression, the significant (independent) predictors* of whether a person sees the FME are:
o Being female o Any age over 18 years o Living in the two most deprived deprivation quintiles and unknown area of
residence o Arrest for violence, public order, breach of bail, sexual offences or under the Mental Health Act
* Those being arrested for fraud and drug offences were significantly less likely to see the FME
56
4. For the group who were seen by Medacs, what was the main reason for call out?
Figure 11 Summary of reasons detainees saw the FME and the main reason for the call out
• The main reason for medical call out in both males and females was whether the detainee was fit to detain, interview, release or attend court.
• For 16% of males and 10% of females, call-out was to administer medications. • Significantly more call-outs to men than to women were for injuries, drink/drug
withdrawal or for reassessment. • Significantly more call-outs to women than to men were for mental health and sexual
offence.
57
Figure 12 Reasons for being seen by an FME by a) Custody suite and b) age (from Medacs data for West Mercia only)
• There is no apparent difference between custody suite in the reason for calling out a medical examiner
• Call-out for injuries and sexual offences were highest in the younger ages groups (under 25) and decreased with age
• Call-out for medications were highest in those aged 25-54 • Call-out for mental health were lowest in those aged 25-34
58
5. Mental Health assessments Figure 13 Proportion of detainees having a medical assessment due to mental
health issues by area of residence (from Medacs data for West Mercia only)
• There was no postcode (and therefore no geography) for 91 of the 637 call-outs due
to Mental Health. • Of the remainder, most 510/546 (93%) were for Warwickshire & West Mercia
residents and 36 were residents of other Police Forces • Overall, 8% of Medacs call-outs were for Mental Health and due to the small number
it is difficult to determine if there was any significant variation across Local Authorities. However, South Worcester (Malvern Hills, Worcester & Wychavon) does appear to record fewer mental health call-outs and Shropshire does appear to record higher rates of mental health call-outs.
• With the exception of a lower rate in Bromsgrove, there didn’t appear to be any correlation between the rate of mental health call-outs per 1,000 people aged 18+ and local area deprivation.
59
Figure 14. a) Location (residence) of FME call out due to Mental Health (where postcode is recorded, n = 546)
b) Location of FME call out due to Mental Health Issues, Warwickshire & West Mercia residents (where postcode is recorded, n = 268)
60 | P a g e
Figure 15 Summary characteristics (predictors) of being seen by the FME for Mental Health assessments - Multiple logistic regression statistics
• When all the variables are entered into a multiple logistic regression, the significant (independent) predictors of being seen by the FME for mental health are:
o Detention at Shrewsbury custody suite o Being female o Arrest for breach of bail/order; and o By far the greatest predictor was arrest under the Mental Health Act
61 | P a g e
7. For the FME group, what was the main outcome of the call out Figure 16 Outcome of medical assessment by FME
• The only outcomes recorded were: advised, attended or cancelled. • Virtually all call-outs for telephone advice were recorded as advised. • For all other reasons, 87-98% were recorded as attended • Overall, 4% of call-outs were cancelled.
Module 3 Detainees’ Views of Healthcare
Findings from Detainee Surveys
A total of 460 detainee surveys were sent out to 7 police stations on 16th October 2013. In the following month long period 34 surveys were returned.
Each station was represented as follows:
• Leamington Spa: 27 (79%) • Shrewsbury: 1 (3%) • Redditch: 0 (0%) • Telford: 0 (0%) • Worcestershire: 6 (18%) • Nuneaton: 0 (0%) • Hereford: 0 (0%)
60 surveys were sent out to every police station except Redditch who were sent 100 by request. The questionnaires were rated either ‘declined’, ‘completed in part’, or ‘fully completed’. In total 22 (65%) were fully completed, 11 ( 32%) were ‘completed in part’ and 1 (3%) was declined.
62 | P a g e
Analysis of the data showed that 28 (82%) of respondents were male, 5 (15%) were female and one respondent did not state their gender. The mean age of detainees was 31 years with a standard deviation of 10 years.
When detainees were asked if they had concerns about their health 7 (21%) replied that they did, 21 (62%) replied that they didn’t and 5 (16%) did not answer the question. Those that did have a health concern were asked to state what kind of concern (some had more than one area of concern). One of the respondents who declined to answer if they had a concern went on to state what kind of concern they had. Therefore in calculating the percentage of respondents who have a particular concern it will be from a total of 8 rather than 7.
Table 4 Summary of detainees responses to their health concerns
Type of Concern Number of Respondents
Percentage of Respondents who reported a health
concern (%) n=8
Percentage of total
respondents surveyed (%)
n=34
Drugs problem 1 13 3 Alcohol problem 2 25 5 Self-harm or suicide 0 0 0 Mental health 3 38 9 Medication 3 38 9 Injuries 0 0 0 Other 2 25 5
Of the concerns listed as ‘other’ one was more of a complaint; the respondent had already listed mental health and medication as a concern:
“Was not given meds on time waited all day illegible diazepam 3 times daily did not get none”
The other answer was “knee”
When asked whether they were offered any help for a health problem whilst in custody 12 (35%) replied yes, 1 (3%) replied no, 16 (47%) replied did not need any and 5 (15%) declined to answer. There was one respondent who reported that he did have a health concern but was not offered any help and one respondent who listed a health concern but stated that he did not need any help. which indicates that 6 people were offered help even though they didn’t have a concern.
Respondents were then asked to rate to what extent the help they were offered met their health needs, 10 (36%) didn’t answer this question. A summary of the responses is listed below:
Table 5 Summary of the extent to which the help detainees were offered met their needs
63 | P a g e
Likert Scale Number of respondents
Percentage of respondents who
rated the help given (%)
n=22
Percentage of total respondents surveyed (%)
n=34
I did not get any help 5 23 15 Not at all 1 5 3 A little 1 5 3 Somewhat 1 5 3 Mostly 5 23 15 Fully 9 41 26
Those who answered that the help that they were offered had either ‘not at all’ met their health needs, or only met them ‘a little’ were asked to state what help they would like to have received. The following responses were given:
• Given my own medication, as prescribed which clearly states times and day • Help with alcohol and mental health • Awaiting medication from 8am and not given Citalopram which needs to taken once
daily
Finally, detainees were asked whether they had been seen by a Doctor, Nurse, Paramedic, Psychiatrist, or ‘other’ health professional. 8 respondents chose not to answer the question. There was some confusion over which box to tick as the layout was such that it appeared
“Psychiatrist □ None□ “
A number of respondents had ticked the box for psychiatrist but hadn’t reported any health problems and presumably meant none. The responses have been adjusted to take account of this. Figure 3 summarises the responses:
Table 6 Summary of health professionals seen by detainees
Health Professional Number of Respondents
Percentage of respondents who
saw a health professional (%)
n=21
Percentage of total respondents surveyed (%)
n=34
Doctor 5 24 15 Nurse 5 24 15 Paramedic 3 14 9 Psychiatrist 0 0 0 None 14 67 41 Other 1 5 3
64 | P a g e
3. Summary of Recommendations
Recommendation 1: There should be close monitoring of response times by the
commissioner as it is likely response times are not being met.
Recommendation 2: It is strongly recommended that in any other future contract negotiations
the role of the nurse, with extended skills, working on site, should be investigated.
Recommendation 3: Joint-protocols between the police and A&E Departments should be
discussed.
Recommendation 4: Greater clarity is required about primary care pathways once the
detainee leaves custody and the role of Primecare in communicating with primary care
agencies.
Recommendation 5: Alongside, Recommendation 3 above, the routine completion of a
discharge summary should be completed by A&E staff at all times.
Recommendation 6: There should be a an agreed understanding between the police and
Primecare of the nature of healthcare that should be provided in custody rather than A&E.
Recommendation 7: Custody sergeants need more specific guidance on the roles of medical
and nursing staff.
Recommendation 8: There should be a log kept of the times that Doctors refuse to attend for
routine procedures.
Recommendation 9: The commissioners should persuade Primecare to re-consider their
policy for the prescription and administration of methadone
Recommendation 10: Detention Officers should be provided with basic training in the
administration of medication.
Recommendation 11: Primecare should undertake an audit of the number of its FMEs that
are Section 12 approved and accordingly inform the commissioners.
Recommendation 12: The current funding basis for the Liaison and Diversion service should
be reviewed.
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Recommendation 13: Funding for a Liaison and Diversion team for West Mercia should be
identified as there is a pressing need for a rapid response service within custody.
Recommendation 14: A protocol, between the Police and the Mental Health Trust, should be
developed with specifies the level of unmanageable risk that the Section 136 suite should
accept.
Recommendation 15: There should be multi-agency agreement reached on alternative
disposals for those with a mental health problem who are frequently arrested.
Recommendation 16: There should be a pan-county review of Section 136 protocols in
advance of the next commissioning round for healthcare in custody in 2015.
Recommendation 17: Given the issues outlined above a mental health improvement plan
should be developed which also addresses learning disability, asperger's and autistic
spectrum disorders.
Recommendation 18: The relevant Local Authorities together with NHS England, should
consider a uniform approach to the commissioning and delivery of DIP services across
Warwickshire and West Mercia, taking into consideration issues of caseload size and
models of intervention (i.e. group v individual work) that best promote recovery outcomes
and value for money.
Recommendation 19: Protocols on the management of detainees with dual diagnosis are
should be agreed for each custody suite between all partner agencies.
Recommendation 20: Guidelines should be in place for Primecare staff to refer on to DIP
services and data relating to the number of referrals should be captured and monitored, also,
leaflets and posters promoting ‘‘recovery’ services should be on display in all custody areas.
Recommendation 21: The commissioners should seek an update report from Primecare on
the project to introduce computer systems into custody suites and how police staff will be
briefed on its intended use – plus issues around access and data sharing.
Recommendation 22: In line with a number of other forces and best practice, commissioners
should consider the commissioning of appropriate adult services to ensure equality of
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access for young people and vulnerable adults indeed, this is a PACE requirement, and no
child or vulnerable adult should be interviewed without an Appropriate Adult.
Recommendation 23: It is recommended that the two police forces consider including the
delivery of specific and relevant healthcare training by a qualified provider within any future
healthcare contract. 4. Conclusion
A multi-disciplinary team, have used a variety of social research methods, to examine
healthcare needs in the main custody suites across West Mercia and Warwickshire Police
force areas. The study has established robust baseline detainee demographics and
triangulation of the data has led to a series of recommendations which will support transition
planning for the transfer of commissioning responsibility of healthcare from the Police to the
NHS in 2015.
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5. References
Bond, P., Kingston, P., and Nevill, A. (2007) Operational Efficiency of Health Care in Police Custody Suites: Comparison of Nursing and Medical Provision, Journal of Advanced Nursing, 60(2): 127-134 Bradley, K. (2009) The Bradley Report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system, London: Department of Health British Medical Association (2009) Health care of detainees in police stations. Guidance from the BMA Medical Ethics Department and the Faculty of Forensic and Legal Medicine, February 2009, London: British Medical Association Bruce, N., Pope D., Stanistreet, D. (2008) Quantitative Methods for Health Research: A Practical Interactive Guide to Epidemiology and Statistics. Wiley: London Department of Health (2007) Improving Health, Supporting Justice, London: Department of Health Dyer. W., Minogue, V., Ali, T., Blades, T., Oates, A., Green, A. (2009) Review of Health Care Delivery in Police Stations North East Region, Department of Health Elvins, M., Gao, C., Hurley, J., Jones, M., Linsley, P., Petrie, D. (2012) Provision of healthcare and forensic medical services in Tayside police custody settings, The Scottish Institute for Policing Research HMIP and HMIC. (2009a) Report on an inspection visit to police custody suites in W a r w i c k s h i r e , available at: http://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmipris/police-cell-inspections/Warwickshire_2009_rps.pdf London: Crown Copyright HMIP and HMIC. (2009b) Report on an inspection visit to police custody suites in W e s t M e r c i a , available at: http://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmipris/police-cell-inspections/West_Mercia_2009_rps.pdf London: Crown Copyright McKinnon, I., Grubin, D. (2010) Health screening in police custody, Journal of Forensic and Legal Medicine, 17: 209-212 Office for National Statistics (2011) Regional Trends Online Tables 01: Key Statistics, June 2011 Release, available at http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-254270 [accessed on 23.2.12] Payne-James, J., Green, P., McLachlan, G., Moore, T. (2010) Healthcare issues of detainees in police custody in London, UK, Journal of Forensic and Legal Medicine, 17: 11-17 Rutten, G. (2009) WYP Custody Health Needs Analysis, unpublished Sirdifield, S., Brooker, C. (2012) Detainees in police custody: results of a health needs assessment in Northumbria, England, International Journal of Prisoner Health, 8, 2, 60-6
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Viggiani de, N., Kushner, S., Last, K., Powell, J., Davies, J. (2010) Police Custody Healthcare: An evaluation of an NHS commissioned pilot to deliver a police custody health service in a partnership between Dorset Primary Care Trust and Dorset Police, Bristol: University of the West of England
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Appendix 1 List of Interviewees for Custody and SARCs Visits
Name Title and Organisation Alison Radbourne
Reactive Constable – Grey’s Mallory
Andy Timms Custody Sergeant – Nuneaton Custody
Amy McDonald CDO – Nuneaton Custody
Gemma Hanlon CID – Nuneaton Custody
Jason Darker PC – Nuneaton Custody
Will Johnston Joint Commissioning Manager – Warwickshire County Council
Donna Hussain Assistant Joint Commissioning Manager – Warwickshire County Council
Ken Johnson Custody Sergeant – Lemmington Spa
John Powell Custody Detention Officer – Lemmington Spa
Vikki Spink Criminal justice mental health liason nurse – CWPT
Michelle Colebrook
Detention Officer
Helen Beer Custody Inspector
Adam Hartwright Detective Sergeant Steve Goddard Lead AMMP / Manager PAT –
Worcestershire Health& Care Trust
Ronnie Perry AA Outside
Sharon Cartwright
Custody Sergeant, West Mercia
Sarah Whelan Arrest Referral Worker – CRI
Darren Keyfe West Mercia
Philip Colley Police Sergeant – West Mercia Police
Stephen Turner Police Inspector – West Mercia Police
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Jerry Coyd Custody Sergeant - West Mercia Police
Sheryl Donnelly Detention Officer – West Mercia
Kyh Phillips Detention Officer – West Mercia
Tracy Ryan Temporary Inspector – West Mercia Police
Alan White D.O
Andy Jackson Custody Sergeant
Eryl Williams Custody RGN
Kirsty Hill Custody Sergeant – West Murcia Constabulary
Sian Tipton Detention Officer - Tascor
Lee Irvine Custody – West Mercia Police
Tracy Swift Police Constable – West Mercia Police
Kelly Browning Detective Constable – West Mercia Police
Valerie Anderson Contract Manager – Primecare Janice Laverick Crisis Worker – G45
Jan Mills Crisis Worker – G45
Denise Griffiths ISVA – Team manager
Victoria Hurdman
Children & Young People’s Worker (CHISYA)
Ian Rutherford Detective Sergeant, Reactive CID - West Mercia Police
Gale Naidoo ISVA Service manager – Axis Consulting
Hannah Walker Coordinator & Crisis Worker - SARC
Emma Durmaz SALC Manager – G45
Simone Newman ISUA – RoSA Cheryl Evans Deputy Manager – SARC
Robyn Marsh Crisis woker – SARC
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Anthony Mumford
Manager - SARC
Jane Burns Custody Nurse
Ben Smith Custody Inspector / LPIT Custody Warwickshire Police