Care and attention for man whilst detained in custody – Thames Valley Police, June 2021

The IOPC recommends that Thames Valley Police reminds police officers who bring members of the public into custody, custody sergeants and healthcare professionals  to be proactive when conducting a risk assessment for a detainee, by reviewing items that belong to the person, whether or not they are still on them or have been seized. When doing so, they should consider whether the items impact on the person’s health and welfare, and align with what the person has informed them on booking in, communicate this to their colleagues and use it to inform the risk assessment being conducted.

This follows an investigation into the death of a man at a Thames Valley Police police station. The man did not inform the custody sergeant that he had taken methadone on the day he had been detained. However, a prescription for methadone was found on his person, which should have indicated that he was likely to have taken the drug that day. This was not listed separately on the man’s personal items on the custody record, or mentioned to the custody sergeant or healthcare professional. Had they been aware of it, it may have impacted on the risk assessment and the decision to prescribe him further medication for heroin withdrawal when he was in custody.

Accepted:

Communication between those working in custody; Thames Valley Police has developed guidance for Custody Staff in relation to the handling of an arrested person’s property. It specifically mentions that all property removed from a detainee must be subject to a risk assessment. In addition to this, as part of the newly introduced “Arresting Officer’s Risk Assessment” document, a specific question is asked within this about any factors that may affect the detainee's physical health or mental wellbeing whilst in custody, which includes items within the arrested person’s property.

Communication between the arresting officer and those transporting the detainee to custody; As previously mentioned, Thames Valley Police has now developed and implemented an “Arresting Officer’s Risk Assessment” document, where critical information about the arrested person is recorded, prior to arrival at the suite, to improve how this is communicated to the Custody Officer by the arresting/escorting officers. This allows for the sharing of any information that may have been disclosed about the arrested person prior to them arriving at the suite. Picking up on the learning from this case, the document also highlights any items in the arrested person’s property, such as medication, that may assist with their safe detention. Following a successful pilot, which included feedback from our staff, this process has now been rolled out across the force. Compliance rates for this are monitored by the custody risk analyst and we are now trialling a digital version of this form. 

Communication during shift handovers between custody officers, staff, and healthcare professionals; Thames Valley Police recognises the importance of ensuring information, particularly regarding risk, is effectively passed between those looking after an arrested person. In respect to our custody staff and in response to the learning from the death of Mr X, the TVP custody management team reviewed our handover process and have now established a set of minimum standards for these. This includes the use of role specific handovers, such as custody officer to custody officer and detention officer to detention officer, to ensure these are relevant and focused on the specific areas of risk the staff need to consider. A mandatory handover template is now also utilised to structure this process with these taking place in an area of the suite covered by CCTV so they are recorded. The new custody sergeant shift pattern, which went live following Mr X's’ death, also builds in a longer handover period between shifts to enable a comprehensive handover to be given. This approach will be mirrored in the new Detention Officer shift pattern that is due to go live in January 2024 which will also see them working alongside their Sergeants to further improve how these staff manage risk and share information.

Monitoring of the quality of cell checks; The Force has now implemented a cell check improvement plan across all 6 of our custody suites. As part of this we have developed additional guidance for all staff and a new training video currently being produced. A new template to record the cell checks has now been implemented to improve how information is recorded on the custody record. A new peer review process has also been introduced where custody records are examined and the quality of the recording of cell checks interrogated to ensure these are delivered in line with the care plan. Alongside this the custody support managers now conduct dip checks, using CCTV, to evaluate the quality of the cell checks and ensure that they are conducted and recorded properly. Where development is identified this is fed back directly to the relevant detention officer. In addition to this the force is currently in the process of producing targeted training for our Detention Officers and Police Constable Detention Officers (PCDOs) in relation to the quality and recording of cells checks. This training was approved through the force training prioritisation board and had resource allocated through the Learning and Professional Development team. Filming for this has already been completed with the rest of the training package, incorporating knowledge checks, in the process of being finalised and, once completed, will be mandated for all custody staff.
    
Medicating new arrivals to custody; Following the death of Mr X, Mountain Healthcare urgently reviewed the care they provided to him, along with their wider policies and procedures. A key element to this review focused on the management of people withdrawing from drink and drugs. As part of this all of our healthcare staff and Custody Officers were reminded of the national guidance that warns against medicating those withdrawing from opiates for six hours after their arrival in custody. This has however been caveated that this is only a guideline and any treatment will always be made using clinical judgement. It is also important to note that, in this case and as per policy, Mr X’s care was overseen by the duty Custody Clinical Coordinator and 2 Forensic Medical Examiners (FMEs). A further critical area which has been thoroughly reviewed is our guidance for the care of detainees with dual dependency on alcohol and drugs. This includes guidance on how to safely manage the simultaneous administration of medication for both alcohol and opiate withdrawal and describes how this should be avoided wherever possible. When this is, however, deemed necessary it states that this must be authorised by a Forensic Medical Examiner (FME), as an additional important safeguard. Furthermore, whilst this guidance supports enhanced checks for detainees who are acutely intoxicated, with a minimum of Level 2 rousing checks every 30 minutes, we recognise the situation where an individual is withdrawing from drugs is very different and so an decision needs to be made, with healthcare support, as to what level of check is appropriate in the specific circumstances presented.

I hope this reassurance that Thames Valley Police has actively progressed the learning identified through the internal critical incident review and the subsequent IOPC investigation. 
 

The IOPC recommends that Thames Valley Police reminds police officers that where the arresting officer does not transport the detainee to custody, information they may have about the detainee is also transferred by some other means and passed on to the custody officer.

This follows an investigation into the death of a man at a Thames Valley Police police station. The detainee informed the arresting officer that he had not taken his methadone prescription that day. The detainee informed the transporting officer that he had not taken any methadone for four days. He also repeated this to the custody officer. Therefore, there was a discrepancy indicating an inaccuracy in the information provided. This was compounded by the fact that a prescription for methadone was found on the detainee but not examined, which indicated that he had probably taken methadone on the day of his arrest – which he had. If the officers and the healthcare professional the detainee saw subsequently were aware of the discrepancy, they could have explored it further. This would have then informed the risk assessment and the decision to prescribe him further medication for heroin withdrawal when he was in custody.

Accepted:

Communication between those working in custody; Thames Valley Police has developed guidance for Custody Staff in relation to the handling of an arrested person’s property. It specifically mentions that all property removed from a detainee must be subject to a risk assessment. In addition to this, as part of the newly introduced “Arresting Officer’s Risk Assessment” document, a specific question is asked within this about any factors that may affect the detainee's physical health or mental wellbeing whilst in custody, which includes items within the arrested person’s property.

Communication between the arresting officer and those transporting the detainee to custody; As previously mentioned, Thames Valley Police has now developed and implemented an “Arresting Officer’s Risk Assessment” document, where critical information about the arrested person is recorded, prior to arrival at the suite, to improve how this is communicated to the Custody Officer by the arresting/escorting officers. This allows for the sharing of any information that may have been disclosed about the arrested person prior to them arriving at the suite. Picking up on the learning from this case, the document also highlights any items in the arrested person’s property, such as medication, that may assist with their safe detention. Following a successful pilot, which included feedback from our staff, this process has now been rolled out across the force. Compliance rates for this are monitored by the custody risk analyst and we are now trialling a digital version of this form.  

Communication during shift handovers between custody officers, staff, and healthcare professionals; Thames Valley Police recognises the importance of ensuring information, particularly regarding risk, is effectively passed between those looking after an arrested person. In respect to our custody staff and in response to the learning from the death of Mr X, the TVP custody management team reviewed our handover process and have now established a set of minimum standards for these. This includes the use of role specific handovers, such as custody officer to custody officer and detention officer to detention officer, to ensure these are relevant and focused on the specific areas of risk the staff need to consider. A mandatory handover template is now also utilised to structure this process with these taking place in an area of the suite covered by CCTV so they are recorded. The new custody sergeant shift pattern, which went live following Mr X's death, also builds in a longer handover period between shifts to enable a comprehensive handover to be given. This approach will be mirrored in the new Detention Officer shift pattern that is due to go live in January 2024 which will also see them working alongside their Sergeants to further improve how these staff manage risk and share information.

Monitoring of the quality of cell checks; The Force has now implemented a cell check improvement plan across all 6 of our custody suites. As part of this we have developed additional guidance for all staff and a new training video currently being produced. A new template to record the cell checks has now been implemented to improve how information is recorded on the custody record. A new peer review process has also been introduced where custody records are examined and the quality of the recording of cell checks interrogated to ensure these are delivered in line with the care plan. Alongside this the custody support managers now conduct dip checks, using CCTV, to evaluate the quality of the cell checks and ensure that they are conducted and recorded properly. Where development is identified this is fed back directly to the relevant detention officer. In addition to this the force is currently in the process of producing targeted training for our Detention Officers and Police Constable Detention Officers (PCDOs) in relation to the quality and recording of cells checks. This training was approved through the force training prioritisation board and had resource allocated through the Learning and Professional Development team. Filming for this has already been completed with the rest of the training package, incorporating knowledge checks, in the process of being finalised and, once completed, will be mandated for all custody staff.
    
Medicating new arrivals to custody; Following the death of Mr X, Mountain Healthcare urgently reviewed the care they provided to him, along with their wider policies and procedures. A key element to this review focused on the management of people withdrawing from drink and drugs. As part of this all of our healthcare staff and Custody Officers were reminded of the national guidance that warns against medicating those withdrawing from opiates for six hours after their arrival in custody. This has however been caveated that this is only a guideline and any treatment will always be made using clinical judgement. It is also important to note that, in this case and as per policy, Mr X’s care was overseen by the duty Custody Clinical Coordinator and 2 Forensic Medical Examiners (FMEs). A further critical area which has been thoroughly reviewed is our guidance for the care of detainees with dual dependency on alcohol and drugs. This includes guidance on how to safely manage the simultaneous administration of medication for both alcohol and opiate withdrawal and describes how this should be avoided wherever possible. When this is, however, deemed necessary it states that this must be authorised by a Forensic Medical Examiner (FME), as an additional important safeguard. Furthermore, whilst this guidance supports enhanced checks for detainees who are acutely intoxicated, with a minimum of Level 2 rousing checks every 30 minutes, we recognise the situation where an individual is withdrawing from drugs is very different and so an decision needs to be made, with healthcare support, as to what level of check is appropriate in the specific circumstances presented.

I hope this reassurance that Thames Valley Police has actively progressed the learning identified through the internal critical incident review and the subsequent IOPC investigation. 
 

The IOPC recommends that Thames Valley Police ensures arrangements are in place for all custody officers, staff and HCPs to receive information about detainees when their shift starts.

This follows an investigation into the death of a man at a Thames Valley Police police station. One of the detention officers involved in the observation of the detainee began their shift later than usual and therefore missed the change of shift briefing. Further, the shift patterns of custody sergeants does not align with that for detention officers of healthcare professionals. By ensuring all those who work in a custody suite have received the same information about detainees, their associated risk assessment and care regime, there can be greater confidence that the person will be given the appropriate level of care and attention.

Accepted:

Communication between those working in custody; Thames Valley Police has developed guidance for Custody Staff in relation to the handling of an arrested person’s property. It specifically mentions that all property removed from a detainee must be subject to a risk assessment. In addition to this, as part of the newly introduced “Arresting Officer’s Risk Assessment” document, a specific question is asked within this about any factors that may affect the detainee's physical health or mental wellbeing whilst in custody, which includes items within the arrested person’s property.

Communication between the arresting officer and those transporting the detainee to custody; As previously mentioned, Thames Valley Police has now developed and implemented an “Arresting Officer’s Risk Assessment” document, where critical information about the arrested person is recorded, prior to arrival at the suite, to improve how this is communicated to the Custody Officer by the arresting/escorting officers. This allows for the sharing of any information that may have been disclosed about the arrested person prior to them arriving at the suite. Picking up on the learning from this case, the document also highlights any items in the arrested person’s property, such as medication, that may assist with their safe detention. Following a successful pilot, which included feedback from our staff, this process has now been rolled out across the force. Compliance rates for this are monitored by the custody risk analyst and we are now trialling a digital version of this form.  

Communication during shift handovers between custody officers, staff, and healthcare professionals; Thames Valley Police recognises the importance of ensuring information, particularly regarding risk, is effectively passed between those looking after an arrested person. In respect to our custody staff and in response to the learning from the death of Mr X, the TVP custody management team reviewed our handover process and have now established a set of minimum standards for these. This includes the use of role specific handovers, such as custody officer to custody officer and detention officer to detention officer, to ensure these are relevant and focused on the specific areas of risk the staff need to consider. A mandatory handover template is now also utilised to structure this process with these taking place in an area of the suite covered by CCTV so they are recorded. The new custody sergeant shift pattern, which went live following Mr X's’ death, also builds in a longer handover period between shifts to enable a comprehensive handover to be given. This approach will be mirrored in the new Detention Officer shift pattern that is due to go live in January 2024 which will also see them working alongside their Sergeants to further improve how these staff manage risk and share information.

Monitoring of the quality of cell checks; The Force has now implemented a cell check improvement plan across all 6 of our custody suites. As part of this we have developed additional guidance for all staff and a new training video currently being produced. A new template to record the cell checks has now been implemented to improve how information is recorded on the custody record. A new peer review process has also been introduced where custody records are examined and the quality of the recording of cell checks interrogated to ensure these are delivered in line with the care plan. Alongside this the custody support managers now conduct dip checks, using CCTV, to evaluate the quality of the cell checks and ensure that they are conducted and recorded properly. Where development is identified this is fed back directly to the relevant detention officer. In addition to this the force is currently in the process of producing targeted training for our Detention Officers and Police Constable Detention Officers (PCDOs) in relation to the quality and recording of cells checks. This training was approved through the force training prioritisation board and had resource allocated through the Learning and Professional Development team. Filming for this has already been completed with the rest of the training package, incorporating knowledge checks, in the process of being finalised and, once completed, will be mandated for all custody staff.
    
Medicating new arrivals to custody; Following the death of Mr X, Mountain Healthcare urgently reviewed the care they provided to him, along with their wider policies and procedures. A key element to this review focused on the management of people withdrawing from drink and drugs. As part of this all of our healthcare staff and Custody Officers were reminded of the national guidance that warns against medicating those withdrawing from opiates for six hours after their arrival in custody. This has however been caveated that this is only a guideline and any treatment will always be made using clinical judgement. It is also important to note that, in this case and as per policy, Mr X's care was overseen by the duty Custody Clinical Coordinator and 2 Forensic Medical Examiners (FMEs). A further critical area which has been thoroughly reviewed is our guidance for the care of detainees with dual dependency on alcohol and drugs. This includes guidance on how to safely manage the simultaneous administration of medication for both alcohol and opiate withdrawal and describes how this should be avoided wherever possible. When this is, however, deemed necessary it states that this must be authorised by a Forensic Medical Examiner (FME), as an additional important safeguard. Furthermore, whilst this guidance supports enhanced checks for detainees who are acutely intoxicated, with a minimum of Level 2 rousing checks every 30 minutes, we recognise the situation where an individual is withdrawing from drugs is very different and so an decision needs to be made, with healthcare support, as to what level of check is appropriate in the specific circumstances presented.
 

The IOPC recommends that Thames Valley Police ensures that the quality of the cell checks conducted by detention officers are regularly monitored by their supervisors, and any concerns are recorded and fed back to them.

This follows an investigation into the death of a man at Thames Valley Police police station. The custody sergeant required the detainee to be checked every 30 minutes by opening the cell hatch, so that detention officers could assess his wellbeing. He was not required to be roused. If a person is awake, the custody staff should communicate with them. If the person is asleep their breathing can be monitored by assessing whether they are visible moving or their chest is rising and falling. Evidence of the cell checks undertaken by the two detention officers who were monitoring the man show they spent just a few seconds looking through the hatch. This is not felt to be sufficient in order to assess someone’s wellbeing. Further, a detention officer assumed that the man was awake because his eyes were open and did not try and communicate with him. Had he done so and not received a verbal response, he would have been alerted to the fact that the man was, at best, unconscious.

By instigating a quality assurance regime for cell checks, errors and poor practice can be identified and remedial measures taken to reduce the risk of matters of concern not being spotted and the necessary action taken.

Accepted:

Communication between those working in custody; Thames Valley Police has developed guidance for Custody Staff in relation to the handling of an arrested person’s property. It specifically mentions that all property removed from a detainee must be subject to a risk assessment. In addition to this, as part of the newly introduced “Arresting Officer’s Risk Assessment” document, a specific question is asked within this about any factors that may affect the detainee's physical health or mental wellbeing whilst in custody, which includes items within the arrested person’s property.

Communication between the arresting officer and those transporting the detainee to custody; As previously mentioned, Thames Valley Police has now developed and implemented an “Arresting Officer’s Risk Assessment” document, where critical information about the arrested person is recorded, prior to arrival at the suite, to improve how this is communicated to the Custody Officer by the arresting/escorting officers. This allows for the sharing of any information that may have been disclosed about the arrested person prior to them arriving at the suite. Picking up on the learning from this case, the document also highlights any items in the arrested person’s property, such as medication, that may assist with their safe detention. Following a successful pilot, which included feedback from our staff, this process has now been rolled out across the force. Compliance rates for this are monitored by the custody risk analyst and we are now trialling a digital version of this form.  

Communication during shift handovers between custody officers, staff, and healthcare professionals; Thames Valley Police recognises the importance of ensuring information, particularly regarding risk, is effectively passed between those looking after an arrested person. In respect to our custody staff and in response to the learning from the death of Mr X, the TVP custody management team reviewed our handover process and have now established a set of minimum standards for these. This includes the use of role specific handovers, such as custody officer to custody officer and detention officer to detention officer, to ensure these are relevant and focused on the specific areas of risk the staff need to consider. A mandatory handover template is now also utilised to structure this process with these taking place in an area of the suite covered by CCTV so they are recorded. The new custody sergeant shift pattern, which went live following Mr X's’ death, also builds in a longer handover period between shifts to enable a comprehensive handover to be given. This approach will be mirrored in the new Detention Officer shift pattern that is due to go live in January 2024 which will also see them working alongside their Sergeants to further improve how these staff manage risk and share information.

Monitoring of the quality of cell checks; The Force has now implemented a cell check improvement plan across all 6 of our custody suites. As part of this we have developed additional guidance for all staff and a new training video currently being produced. A new template to record the cell checks has now been implemented to improve how information is recorded on the custody record. A new peer review process has also been introduced where custody records are examined and the quality of the recording of cell checks interrogated to ensure these are delivered in line with the care plan. Alongside this the custody support managers now conduct dip checks, using CCTV, to evaluate the quality of the cell checks and ensure that they are conducted and recorded properly. Where development is identified this is fed back directly to the relevant detention officer. In addition to this the force is currently in the process of producing targeted training for our Detention Officers and Police Constable Detention Officers (PCDOs) in relation to the quality and recording of cells checks. This training was approved through the force training prioritisation board and had resource allocated through the Learning and Professional Development team. Filming for this has already been completed with the rest of the training package, incorporating knowledge checks, in the process of being finalised and, once completed, will be mandated for all custody staff.
    
Medicating new arrivals to custody; Following the death of Mr X, Mountain Healthcare urgently reviewed the care they provided to him, along with their wider policies and procedures. A key element to this review focused on the management of people withdrawing from drink and drugs. As part of this all of our healthcare staff and Custody Officers were reminded of the national guidance that warns against medicating those withdrawing from opiates for six hours after their arrival in custody. This has however been caveated that this is only a guideline and any treatment will always be made using clinical judgement. It is also important to note that, in this case and as per policy, Mr X's care was overseen by the duty Custody Clinical Coordinator and 2 Forensic Medical Examiners (FMEs). A further critical area which has been thoroughly reviewed is our guidance for the care of detainees with dual dependency on alcohol and drugs. This includes guidance on how to safely manage the simultaneous administration of medication for both alcohol and opiate withdrawal and describes how this should be avoided wherever possible. When this is, however, deemed necessary it states that this must be authorised by a Forensic Medical Examiner (FME), as an additional important safeguard. Furthermore, whilst this guidance supports enhanced checks for detainees who are acutely intoxicated, with a minimum of Level 2 rousing checks every 30 minutes, we recognise the situation where an individual is withdrawing from drugs is very different and so an decision needs to be made, with healthcare support, as to what level of check is appropriate in the specific circumstances presented.
 

The IOPC recommends that Thames Valley Police should remind custody officers and medical professionals that its guidance warns against medicating those withdrawing from opiates for six hours after arrival in custody due to any doubt as to what they have taken.

This follows an investigation into the death of a man at Thames Valley Police police station. Thames Valley Police guidance states that it is normal policy for medication to be withheld in order to reduce the risk of overdose and interaction with other drugs that detainees may have taken is considerably reduced.

When the man was first detained he informed the arresting police officer he had not taken any methadone that day. He subsequently told the police officers transporting him that he had not taken any methadone for four days, and repeated this to the custody sergeant. Contained within the man’s property was a prescription for methadone, which would have indicated that he had probably taken methadone that day, which he had. Therefore, there was discrepancy in the evidence available and what the man had told police officers. The man was displaying signs of withdrawal when he arrived in custody at 6.15pm. He saw a healthcare professional and at 8.23pm she prescribed him opiate and alcohol withdrawal medications. It should be noted that the medication prescribed did not contribute to the man’s cause of death.

Accepted:

Communication between those working in custody; Thames Valley Police has developed guidance for Custody Staff in relation to the handling of an arrested person’s property. It specifically mentions that all property removed from a detainee must be subject to a risk assessment. In addition to this, as part of the newly introduced “Arresting Officer’s Risk Assessment” document, a specific question is asked within this about any factors that may affect the detainee's physical health or mental wellbeing whilst in custody, which includes items within the arrested person’s property.

Communication between the arresting officer and those transporting the detainee to custody; As previously mentioned, Thames Valley Police has now developed and implemented an “Arresting Officer’s Risk Assessment” document, where critical information about the arrested person is recorded, prior to arrival at the suite, to improve how this is communicated to the Custody Officer by the arresting/escorting officers. This allows for the sharing of any information that may have been disclosed about the arrested person prior to them arriving at the suite. Picking up on the learning from this case, the document also highlights any items in the arrested person’s property, such as medication, that may assist with their safe detention. Following a successful pilot, which included feedback from our staff, this process has now been rolled out across the force. Compliance rates for this are monitored by the custody risk analyst and we are now trialling a digital version of this form.  

Communication during shift handovers between custody officers, staff, and healthcare professionals; Thames Valley Police recognises the importance of ensuring information, particularly regarding risk, is effectively passed between those looking after an arrested person. In respect to our custody staff and in response to the learning from the death of Mr X, the TVP custody management team reviewed our handover process and have now established a set of minimum standards for these. This includes the use of role specific handovers, such as custody officer to custody officer and detention officer to detention officer, to ensure these are relevant and focused on the specific areas of risk the staff need to consider. A mandatory handover template is now also utilised to structure this process with these taking place in an area of the suite covered by CCTV so they are recorded. The new custody sergeant shift pattern, which went live following Mr X's’ death, also builds in a longer handover period between shifts to enable a comprehensive handover to be given. This approach will be mirrored in the new Detention Officer shift pattern that is due to go live in January 2024 which will also see them working alongside their Sergeants to further improve how these staff manage risk and share information.

Monitoring of the quality of cell checks; The Force has now implemented a cell check improvement plan across all 6 of our custody suites. As part of this we have developed additional guidance for all staff and a new training video currently being produced. A new template to record the cell checks has now been implemented to improve how information is recorded on the custody record. A new peer review process has also been introduced where custody records are examined and the quality of the recording of cell checks interrogated to ensure these are delivered in line with the care plan. Alongside this the custody support managers now conduct dip checks, using CCTV, to evaluate the quality of the cell checks and ensure that they are conducted and recorded properly. Where development is identified this is fed back directly to the relevant detention officer. In addition to this the force is currently in the process of producing targeted training for our Detention Officers and Police Constable Detention Officers (PCDOs) in relation to the quality and recording of cells checks. This training was approved through the force training prioritisation board and had resource allocated through the Learning and Professional Development team. Filming for this has already been completed with the rest of the training package, incorporating knowledge checks, in the process of being finalised and, once completed, will be mandated for all custody staff.
    
Medicating new arrivals to custody; Following the death of Mr X, Mountain Healthcare urgently reviewed the care they provided to him, along with their wider policies and procedures. A key element to this review focused on the management of people withdrawing from drink and drugs. As part of this all of our healthcare staff and Custody Officers were reminded of the national guidance that warns against medicating those withdrawing from opiates for six hours after their arrival in custody. This has however been caveated that this is only a guideline and any treatment will always be made using clinical judgement. It is also important to note that, in this case and as per policy, Mr X's care was overseen by the duty Custody Clinical Coordinator and 2 Forensic Medical Examiners (FMEs). A further critical area which has been thoroughly reviewed is our guidance for the care of detainees with dual dependency on alcohol and drugs. This includes guidance on how to safely manage the simultaneous administration of medication for both alcohol and opiate withdrawal and describes how this should be avoided wherever possible. When this is, however, deemed necessary it states that this must be authorised by a Forensic Medical Examiner (FME), as an additional important safeguard. Furthermore, whilst this guidance supports enhanced checks for detainees who are acutely intoxicated, with a minimum of Level 2 rousing checks every 30 minutes, we recognise the situation where an individual is withdrawing from drugs is very different and so an decision needs to be made, with healthcare support, as to what level of check is appropriate in the specific circumstances presented.
 

The IOPC recommends that a review of PACE Code C Annex H is undertaken in relation to the guidance on dealing with detainees withdrawing from drugs and alcohol, including withdrawal symptoms masking other serious problems. The review should include consideration of the dangers of dual medication and amendments to PACE Code C Annex H, point 3, adding that a person who is drowsy and smells of alcohol may also have alcohol-related fatty liver disease.

This follows an investigation into the death of a man at Thames Valley Police police station. The man died from alcohol-related fatty liver disease. At the time of his death, he was withdrawing from class A drugs and alcohol and had been prescribed medication whilst in custody to alleviate the symptoms associated with withdrawal.

People with alcohol-related fatty liver disease do not have any noticeable symptoms until their liver is badly damaged. Symptoms may include: abdominal pain; loss of appetite; fatigue; feeling sick; diarrhoea; and feeling generally unwell. Many of these symptoms are also associated with drug and alcohol withdrawal. Therefore, alcohol-related fatty liver disease was not considered as a potential cause of the detainee’s ailments. A precise diagnoses of alcohol-related fatty liver disease is unlikely to be possible within a custody environment due to the tests required, therefore consideration should be given as to the presence of this disease and referral to hospital to ensure appropriate treatment is given and to reduce the risk of sudden death.

Accepted:

Proposal from the IOPC:
The IOPC proposed a review of guidance on managing detainees who are withdrawing from drugs and alcohol. The IOPC requested that the guidance includes clear advice on managing detainees in police custody who are withdrawing from both alcohol and drugs to ensure there is clear information and advice on: 
a) The signs and symptoms of withdrawal potentially masking other medical conditions or 
complications. 
b) The risks associated with issuing medication for alcohol and drug withdrawal at the same 
time, including circumstances in which it might be appropriate to dual medicate and how to mitigate any risks. 

This request followed an investigation into the death of a man at a police station within the area of Thames Valley Police. The man died from alcohol-related fatty liver disease. At the time of his death, he was withdrawing from class A drugs and alcohol and had been prescribed medication whilst in custody to alleviate the symptoms associated with withdrawal from both substances. The investigation raised concerns that dual treatment for withdrawal of both alcohol and opiates may be high risk because breathing can be made harder from the medication depressing the central nervous system, potentially creating an increased risk of death. The investigation noted that people with alcohol-related fatty liver disease do not have any noticeable symptoms until their liver is badly damaged. Symptoms may include abdominal pain, loss of appetite, fatigue, feeling sick, diarrhoea, and feeling generally unwell. Many of these symptoms are also associated with drug and alcohol withdrawal. Therefore, alcohol-related fatty liver disease was not considered as a potential cause of the detainee’s ailments. A precise diagnosis of alcohol-related fatty liver disease is unlikely to be possible within a custody environment due to the tests required, therefore consideration should be given as to the possible presence of this disease and referral to hospital to ensure appropriate treatment is given and to reduce the risk of sudden death.

FFLM comments:
On further discussion and review of the pathologist’s report, it was established that the likely  cause of death was an arrhythmia resulting from metabolic disturbance due to the alcohol related fatty liver disease. The symptoms that the gentleman presented with were also consistent with drug and alcohol  withdrawal and there was an established history of drug and alcohol use. We agreed that the  healthcare professional acted appropriately by treating presumed drug and alcohol withdrawal. 

We also acknowledged that the healthcare professional was not aware that the gentleman had  obtained a script for methadone and had taken a dose prior to his detention. 
The guidance used for management of drug and alcohol withdrawal is referred to as the ‘Blue Book’ and is a document entitled: Detainees with substance use disorder in Police Custody: 
Guidelines for Clinical Management (5th Edition) March 2020: 
https://fflm.ac.uk/resources/publications/detainees-with-substance-use-disorders-in-policecustody-guidelines-for-clinical-management-5th-edition.

The Blue Guidelines outline the management of detainees with substance use disorder in police  custody. Appendix A has a list of the required competencies for clinicians working with detainees  with substance use disorders in police custody. Providers of clinical forensic medical services  are responsible for ensuring that their staff are trained to the required level.

The IOPC have requested that the FFLM review the guidance to ensure that FFLM publications  highlight that the signs and symptoms of withdrawal potentially mask other medical conditions  or complications. In any healthcare assessment, professionals follow a process that should  involve history and examination, concluding with a list of differential diagnoses and formulating  a management plan. The formulation of a list of differential diagnoses should include other  possible causes for the presentation. The FFLM agrees that highlighting other possible medical  conditions that may present with similar symptoms to withdrawal is beneficial. It was agreed that  one of the best ways to ensure other diagnoses are not missed would be to re-enforce the  guidance in the ‘Blue Book’ to review any detainee treated for withdrawal to ensure that they are  responding to treatment as expected and to prompt exploration of other differential diagnoses if not.

On discussion with Prof [redacted] about the risks of dual diagnosis, we do not agree with 
the IOPC’s finding that there is a risk of sedation in those treated appropriately with opiates and  benzodiazepines for dual dependence. If a detainee is withdrawing from both alcohol and  opiates, the risk of being medicated for both is minimal. To ensure the diagnosis of drug and  alcohol withdrawal, an accurate history must be taken to establish dual dependency and a thorough examination conducted to make the diagnosis. It is acknowledged that this may be  challenging if a detainee’s medical history cannot be confirmed with other healthcare agencies.

Summary
In response to the meeting and request for a review of the guidance on managing detainees 
who are withdrawing from drugs and alcohol, the FFLM agree to:
• Remind practitioners of the ‘Blue Book’ which contains all relevant guidance. 
• Offer webinars based on the management of drug and alcohol withdrawal in custody, which 
will enable us to highlight the learning from this case. 
• Review how healthcare professionals receive information regarding healthcare issues, to 
try and ensure that those treating detainees have access to relevant information where 
possible, such as having the information that his gentleman had received a dose of 
methadone.
• Ensure that all those in custody are receiving appropriate opiate substitution therapy (OST) 
and if they are on a script for OST this is maintained where possible while in custody. 
• Continue to include ‘Learning the Lessons’ which summarise cases with IOPC involvement 
in our weekly newsletter. 
• Offer a webinar to discuss some of the cases in ‘Learning the Lessons.’
• Collaborate further with the IOPC to continue to raise standards in custody healthcare. 
The FFLM has already encouraged its members to respond to the consultation on UK clinical 
guidelines for alcohol treatment: https://www.gov.uk/government/consultations/uk-clinical guidelines-for-alcohol-treatment.
The FFLM continues to seek speciality status which would ensure all those working in this setting  are reaching expected competencies, and the specialist nature of this high-risk work is more  widely recognised.