Recommendations - Bedfordshire Police, July 2021
We identified organisational learning from a death or serious injury report. It relates to a matter where a person had a suspected heart attack while in custody and received medical treatment by officers.
IOPC reference
Recommendations
The IOPC recommends that Bedfordshire Police reviews the current process of medical examinations being documented on paper records when problems are encountered with the Athena system, to ensure that copies of the paper records are shared immediately with custody sergeants for use during staff handovers. Bedfordshire Police should also review the process of retrospectively uploading the details held on paper records to the Athena system at a later date, to ensure that it is fit for purpose and that all relevant information is accurately recorded.
This learning recommendation has arisen following the IOPC’s review of a DSI matter, during which a detainee was transferred to hospital having after suffering a suspected heart attack. It has been established that following an initial consultation, the HCP had advised that the detainee should be re-assessed again an hour later. However, this information was recorded on a paper record and does not appear to have been noted by the custody sergeant, or referenced during the handover which subsequently took place. The paper record was completed due to the Athena system being unavailable at that time. It is unclear if the custody sergeants had been provided with a copy of the paper record and it also appears that when the information was eventually uploaded onto the Athena system, this information was omitted.
Accepted:
Revised SOPS will contain information on the process of paperwork, that is supplementary to the Athena custody record.
The Custody Operating Procedure will be updated to ensure that all custody staff (sergeants and detention officers) are aware of the requirement to scan and attach paper medical notes to the Athena custody record document management as soon as it is provided by the HCP. If this is completed by a detention officer, then the Custody Officer responsible for the detainee must be informed. This does not negate the requirement for the HCP to inform the custody officer of the outcome of the medical assessment, and any recommendations.
The IOPC recommends that Bedfordshire Police review the way that handovers are conducted by custody sergeants, to ensure that they are carried out effectively, in an appropriate setting and free from distractions where reasonably practicable. Consideration should also be given to the guidance set out in the college of Policing Detainee Care Authorised Professional Practice (APP), which states “ If handover has to take place in or around the booking-in desks, the custody suite should be cleared of other personnel. Custody officers and other custody staff should carry out the handover together .”
This learning recommendation has arisen following the IOPC’s review of a DSI matter, during which a detainee was transferred to hospital having after suffering a suspected heart attack. When viewing CCTV footage of the handover between custody sergeants, it is shown that a number of other staff members entered the area where the conversation took place. This may have distracted the custody sergeants and reduced the effectiveness of the handover. The conversations between the other staff members also obscured the conversation which did take place between the custody sergeants.
Accepted:
Handovers must be detailed. APP guidance for handovers states: “The information entered should include the risks, disabilities, medical needs, vulnerabilities, emerging issues, control strategies and welfare needs of each detainee. It should also cover the status of each investigation, including the actions required to achieve effective and lawful resolution of the matter for which the person has been detained. The incoming shift of custody officers and staff must ensure that they are aware of all of this information.”
HCPs should be present during the handover, and whenever this is not possible, a separate meeting should take place between the oncoming custody staff and the HCP, covered by CCTV and audio recording to ensure that all parties are aware of the current medical risks.
Bedfordshire Police should provide guidance to custody sergeants in respect of ensuring that a Health Care Professional (HCP) is present during handovers between staff when practicable. This will ensure that custody sergeants are provided with accurate and up-to-date information about a detainee’s medical condition and informed about any future considerations about the detainee’s care. The IOPC is of the view that this learning recommendation should be implemented as soon as practicable, so that such scenarios as this can be avoided in the future.
This learning recommendation has arisen following the IOPC’s review of a DSI matter, during which a detainee was transferred to hospital having after suffering a suspected heart attack. It appears that the custody sergeant who received the handover in this case did not have up-to-date information about the detainee’s medical condition. The learning recommendation in respect of a HCP participating in the handover has been discussed by the officer who investigated the DSI, however it was stated that Chief inspector [redacted] has proposed this being implemented once Covid restrictions are lifted. The IOPC is of the view that this learning recommendation should be implemented as soon as practicable, so that such scenarios as this can be avoided in the future.
Accepted:
This approach has now been adopted by Herts and Beds Custody Operating Procedure will also be updated.