Complaints raised in relation to detention in custody – Essex Police, June 2020
In June 2020, a complaint was made that Essex Police kept a woman in police custody for an excessive length of time and did not provide adequate support for her mental wellbeing during her detention. In addition, a further complaint was made that Essex Police had victimised the woman over the last nine years.
Our investigation considered whether the appropriate welfare measures were put in place in relation to the woman’s mental wellbeing, the length of time that she was in custody and whether all of the actions were conducted in line with legislation, policy and procedure, and were proportionate and necessary.
We investigated whether there was a pattern of incidents which indicated whether the woman was victimised by Essex Police by establishing the amount of contact she had with the force since early 2018 and establishing whether the contact was proportionate and for a legitimate policing purpose.
During our investigation, we took an account from the woman as the complainant regarding her treatment in custody. We also took statements from nine police officers and three medical professionals. We examined crime logs, incident logs, radio transmissions and compared the evidence to relevant policies and procedures.
Our investigation concluded in September 2021. We consulted with the force over potential learning and finalised recommendations before publishing our findings.
After reviewing all evidence, no complaints were upheld. Our investigation found no indication of misconduct against any police officer.
Having reviewed the evidence, the woman was not deemed to need a Mental Health Act Assessment and therefore, did not need to be taken to a place of safety. The woman’s continued detainment was reasonable and in line with the guidance and legislation, and appropriate measures were put in place to safeguard the woman. The evidence gathered also demonstrated that her mental wellbeing was suitably considered during her time in custody.
We reviewed all Essex police contact at the woman’s address since early 2018. The evidence indicated that each incident was attended for a legitimate policing purpose, and the level of response including the number of officers deployed, was seemingly proportionate to the type of incident and the apparent risk level perceived.
We carefully considered whether there were any learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system and prevent a recurrence of similar incidents. We identified organisational learning in several areas to improve working practice and consulted with Essex Police.
We recommended officers are reminded of certain responsibilities while conducting level 4 constant observations and the importance of recording decisions and rationale in writing. We recommended that reasons for not administering medication claimed to be necessary by a detainee, should be recorded on the custody record; consideration should also be given for a clear policy relating to this expectation. Rationale and decision-making should also be reflected on the custody record when a detainee has retained jewellery while in custody. We also encouraged improved practice to manage and assist with a detainee who has been incontinent while in detention.
We issued both Section 10 and Paragraph 28A recommendations to Essex Police under Schedule 3, Police Reform Act 2002.
IOPC reference
Recommendations
The IOPC recommends that Essex Police remind all Custody Staff of their policy in relation to assigning female carers to female detainees.
A female complainant was detained in police custody for around 35 hours. Essex Police have a policy that all female detainees should be assigned a 'female carer' for the duration of their detention, and a replacement female carer should be assigned when a Custody Sergeant hands over to the next Custody Sergeant, or when the female carer’s shift ends. In this case, the complainant was assigned a female carer by the Custody Sergeant who booked her in. Due to the length of the complainants’ detention, multiple Custody Sergeants were in charge of her detention. However, the complainant was not assigned a female carer by any of these Custody Sergeants.
Do you accept the recommendation?
Yes
Accepted action:
Action; Instruction was sent to all custody staff on 3rd March 2022. This is now included as part of our monthly audit and inspection process. Custody records are dip checked to ensure that the allocation of a female carer and their introduction to the detainee has been recorded. Any subsequent reallocation of another carer due to a shift change is also checked as part of the audit. 25th April 2022 Instruction sent to all custody staff informing them of this recommendation and placed on our Custody Command ‘learning the lessons’ briefing page.
The IOPC recommends that Essex Police should amend their policy to ensure that where a Health Care Professional (HCP) decides not to administer a medication that they have been informed a detainee has been prescribed, the HCP should record this decision as part of their clinical findings and directions.
Essex Police’s policy currently states that HCPs should record clinical findings and directions for the care of a detainee on the custody record. It does not explain what a HCP should do if a detainee is not given a medication that they say they need. In this investigation, a complainant was in custody for around 35 hours. When she was booked into custody, she told custody staff the name of two medications she took. She was only given one of the medications whilst in custody. It is not clear from the custody log nor the HCP assessments why the second medication was not given. However, a number of plausible reasons were offered by the HCP's during the investigations process.
Do you accept the recommendation?
Yes
Accepted action:
Action: This request was submitted to our Health Care provider CRG 1st April 2022 confirmation received that it was circulated to their staff as a new recording requirement.
A request to update our current policy E0101 has been submitted.
The IOPC recommends that Essex Police takes steps to ensure all relevant referrals are made for detained persons. This should include consideration of providing guidance on how to make referrals, including who is responsible for doing so and ensuring that decision making is recorded.
A complainant was in police custody for around 35 hours. She has mental health conditions which were exacerbated during her time in custody, and on two occasions made attempts to harm herself. She was on level four constant observations. Following charge, the officer in charge's (OIC) line manager requested that he make 'relevant social services referrals'. The complainant had seen a mental health diversion and liaison worker, who had said they would make mental health referrals for the complainant. The OIC did not make any referrals for the complainant. They provided their reason for this during the investigation process, which included that they would have expected the Liaison and Diversion service to do this. However, they did not record their decision on the custody log, or on the crime report. Therefore, without investigation, it was not possible to see whether the referrals had been considered, or made. The recording of such decision would remove any likelihood of speculation and potential associated risk. The investigation found no policy or guidance in relation to who is responsible for making referrals.
Do you accept the recommendation?
No
Accepted action:
Liaison & Diversion referrals are the responsibility of the Health Care providers within custody and are stipulated within the current Health Care contract. All referrals are made with the consent of the detainee following their engagement with the Health Care professionals in custody. The EPUT report record the referrals that were made.
This relevant referral in this case related to a request contained within the OIC’s supervisor’s disposal decision where the Sergeant requested that the OIC made a referral to social services, but despite this direction, the referral was made on this occasion. This has been fully addressed with the individual concerned but from an organisational perspective, various communications and training has been delivered across the force around the criteria and processes for making referrals to other agencies.
The IOPC recommends that Essex Police take steps to ensure custody staff, in particular custody officers and healthcare professionals, understand when detained persons require an Appropriate Adult. This should include:
Providing updated training on the legislation and national guidance regarding the provision of Appropriate Adults.
Updating custody policies and procedures on Appropriate Adults to ensure they are consistent with PACE Code C.
A complainant was in police custody for around 35 hours. She had mental health conditions and was deemed vulnerable by the Custody Sergeant when she was booked into custody. However, the Custody Sergeant did not request an Appropriate Adult (AA), nor did any of the further Custody Sergeants in charge of her detention. The complainant was assessed by multiple different Health Care Professionals (HCP’s), all of whom recorded that an Appropriate Adult was not recommended. The complainant was interviewed when in custody, during which time the officer in the case (OIC) took responsibility for her. The OIC did not ask for an Appropriate Adult to be provided. While this is ultimately the Custody Sergeants decision, under PACE Code C a vulnerable person should not be interviewed without an AA.
Do you accept the recommendation?
Yes
Accepted action:
25th April 2022 Communication sent to all custody Sgts reminding them of their responsibility under PACE Code C. Force policy does not need to reinforce what is already a lawful requirement.
Instruction sent to all custody staff informing them of this recommendation and reminding them of their responsibilities under PACE C, 1.13 (D) and placed on our Custody Command ‘learning the lessons’ briefing page.
The IOPC recommends that Essex Police remind all police officers and custody staff of their responsibility to sign the constant observations front sheet following a briefing from a Custody Sergeant, and the Custody Sergeant's responsibility to countersign the entry.
A complainant was in police custody for around 35 hours. She had mental health conditions and was deemed vulnerable by the Custody Sergeant, and therefore was put on level four constant observations. When conducting a constant observation, the officer should go to the custody front desk for a briefing and add their name to the constant observation front sheets. The Custody Sergeant should then countersign the entry. In this case, three officers did not add their name to the front sheets to say they had received a briefing, and therefore the Custody Sergeant did not counter sign it.
Do you accept the recommendation?
Yes
Accepted action:
The hard copy PERS form used in 2019 for PECS transfers has now been replaced by an electronic version called dPERS . The warning markers section is integrated into this electronic application and is not added as a separate sheet. This recommendation is no longer applicable as the process.
Checks on the accuracy of warning markers recorded on the dPERS is has since been included as part of the custody Inspectors monthly audit checks.
The IOPC recommends that Essex Police provide training to all custody officers in relation to the forms they should complete when transferring detainee's to other agencies for Court.
A complainant was denied bail following charge for an offence, and therefore was transferred to SERCO for court. The complainant had mental health conditions and tried to self-harm in custody twice during her 35 hour detention. Upon transfer to SERCO, the Custody Sergeant completed a Prisoner Escort Record Form (PER). They did not attach a 'suicide/self harm warning form', however they did include the relevant information on the PER.
Do you accept the recommendation?
Yes
Accepted action:
The hard copy PERS form used in 2019 for PECS transfers has now been replaced by an electronic version called dPERS . The warning markers section is integrated into this electronic application and is not added as a separate sheet. This recommendation is no longer applicable as the process.
Checks on the accuracy of warning markers recorded on the dPERS is has since been included as part of the custody Inspectors monthly audit checks.
The IOPC recommends that Essex Police ensure that officers conducting close proximity observations in custody are of the appropriate sex.
A complainant was in police custody for 35 hours. She had mental health conditions and was placed on level four close proximity observations. She was left with the drawstring in her trousers, due to the fact that she was on close proximity observations which lessened the risk of her being able to use this to self-harm. When the detainee used the toilet, the officer conducting constant observations did not directly watch the complainant, and during this time she was able to remove the string and then used it to self-harm. The complainant was female and the officer conducting constant observations was male. Through investigation it became clear that there is no guidance in relation to discussing this type of risk during the Custody Sergeant's briefing. In addition, Essex Policy states that constant observations should be carried out by someone of the appropriate sex.
Do you accept the recommendation?
Yes
Accepted action:
25th April 2022 Instruction sent to all custody staff informing them of this recommendation and placed on our Custody Command ‘learning the lessons’ briefing page.
This is also contained in Essex Police policy E0104 section 3.2.4 on close proximity constants:
Detainees at the highest risk of self-harm should be observed at this level. It requires the following:
- Issues of privacy, dignity and gender are taken into consideration;
The IOPC recommends that Essex Police should review its policy and procedures to clarify and improve existing guidance in relation to:
The length of time officers should conduct close proximity observations before they are replaced by another officer.
What is expected of officers who are conducting close proximity observations, including what is not appropriate while completing such observations.
The complainant was in Police Custody for around 35 hours due to being charged with an offence and denied bail. The complainant was put on level four close proximity observations, which meant an officer was placed in her cell observing her for the duration of her detention. The investigation found that some officers were close proximity observations for a significant period of time, and that one officer wrote their statement whilst conducting the observations. The investigation has found no policy or guidance on the length of time officers should conduct close proximity observations or what is expected officers who are conducting such observations.
Do you accept the recommendation?
Yes
Accepted action:
Action
Point 1 – Essex Police are already developing an automated system where the custody Sgt and the supervising officer of the officers conducting constant observations are reminded to provide relief cover. Once this system had been developed it will be trailed in the South LPA. 25th April 2022 Instruction sent to all custody staff informing them of this recommendation and placed on our Custody Command ‘learning the lessons’ briefing page
Point 2 –The constant observation form already contains explicit instructions to officers conducting constant observation as to the requirements of the role (Form A345 page 2). On 25th April 2022 Instruction was sent to all custody Sgts reminding them of this recommendation and their duty covering these instructions with officers. This instruction has been and placed on our Custody Command ‘learning the lessons’ briefing page
Please note that contrary to paragraph 195 of this report which stated ‘This investigation found no policy or guidance on what is expected of an officer whilst conducting constant observations’ is incorrect. The constant observations form A345 does contain written instructions to officers on the requirements of their role. This can be found on page 2 of the A345. In this case the instruction page 2 was not uploaded to the document manager in Athena however all 3 pages are stapled together and handed to the officers.
Essex Police policy E0104 section 3.2.4 also contains instruction to officers conducting constant observations:
3.2.4 Level 4 - Close Proximity
Detainees at the highest risk of self-harm should be observed at this level. It requires the following:
- The detainee is physically supervised in close proximity;
- CCTV and other technologies do not meet the criteria of close proximity but may complement this level of observation;
- Issues of privacy, dignity and gender are taken into consideration;
- Any possible ligatures are removed;
- The detainee is positively engaged at frequent and irregular intervals;
- Observations, including the detainee's behaviour/condition, must be recorded in the custody record;
- Any change in behaviour/condition must be reported to the custody sergeant immediately;
- Review by FME or HCP (as appropriate);
- Officers charged with visual control of the detainee, under Level 4 shall:
- Be provided by the Custody Officer with the relevant procedural briefing document governing Level 4 observations and familiarise themselves with it prior to undertaking these duties;
- Be in possession of an anti-ligature cutter.
- Officers charged with these duties must maintain constant observation of the detainee at all times and must be free from any and all distractions. For example:
- The use of any mobile device is prohibited;
- No reading material should be accessed;
- Conversations with other officers that would otherwise take the attention away from the detained person should be minimised.
The custody sergeant must record the following on the custody record:
- The level of observation required;
- The reasons for that decision;
- Be reviewed periodically and at each handover of Sergeant.
It is recommended that any officer carrying out Level 4 observations is replaced by another after 2 hours if practicable.
In circumstances involving the risk of self-harm the detainee’s hands and face must be visible to the officer at all times, even if this requires the removal of any blanket or clothing used by the detainee to cover themselves.
When cell checks and visits are carried out it is not sufficient to record 'visit correct' or 'checked in order' on the custody record. More detail is required, e.g. 'detainee awake, reading, spoken to, offered a drink, drink refused'.
The IOPC recommends that Essex Police take steps to ensure that all custody staff pro-actively offer showers to detainees during their detention in police custody. As a minimum, detainees should be offered a shower if they have been incontinent. Appropriate steps could include providing updated guidance, training, and force communications to custody staff.
This follows an investigation where a complainant was held in police custody for around 35 hours. When she was booked into custody, she was offered a shower. Whilst detained, she was incontinent. While the complainant was provided with a change of clothes, it is not clear from the custody record whether she was offered a shower at the time. The complaint was given a shower at her request around 26 hours later, before she was due to appear in court.
Do you accept the recommendation?
Yes
Accepted action:
Action - 25th April 2022 Instruction sent to all custody staff informing them of this recommendation and placed on our Custody Command ‘learning the lessons’ briefing page.