An investigation into complaints made about the treatment of a man with epilepsy - South Wales Police,
On 7 March 2020, a 19-year-old man and his family were visiting relatives in South Wales. The young man had severe epilepsy and psychosis and had recently been released from a specialist epilepsy hospital. During the family visit, he experienced a psychotic episode which led him to become distressed and aggressive towards his father. The man’s mother phoned for the police to attend, to take him to a place of safety.
Two police officers arrested the man for assaulting his father. They detained him using manual restraint, incapacitant spray and two sets of handcuffs. Other officers arrived at the scene to take witness statements from the man’s parents. The man’s parents provided the man’s prescribed epilepsy medication, which was taken to custody by one of the arresting officers. The man’s parents stated that they told officers that their son had epilepsy and learning disabilities and would need to take his medication.
The man was taken to custody. He was assessed by a custody nurse, who recommended that he receive a mental health assessment. His parents stated that they telephoned the custody unit and asked the custody staff whether the man had been given his epilepsy medication but were told he had not been given the medication. They then attended the custody unit in person. The man was assessed by a different custody nurse and was provided with his medication. He was then taken to a local hospital psychiatric unit for assessment, where he was pronounced not fit to be detained. The charges of assault on his father were later dropped by the police.
The man’s mother wrote a letter of complaint to South Wales Police on 14 May 2020 and complained about the use of force by officers on her son at the scene of his arrest and the treatment of her son in police custody.
During the investigation, investigators interviewed the complainants and obtained written responses from the police officers, custody sergeants, custody detention officers and healthcare professionals involved in the arrest and detention of the young man. Investigators also obtained policies and procedures regarding use of force, and detention and custody.
We concluded the service provided by the police was unacceptable and that two officers should reflect on their handling of this matter through the Reflective Practice Review Process (RPRP).
An officer reflecting on their actions is a formal process reflected in legislation. RPRP consists of a fact-finding stage and a discussion stage, followed by the production of a reflective review development report. The discussion must include:
- a discussion of the practice requiring improvement and related circumstances that have been identified, and
- the identification of key lessons to be learnt by the participating officer, line management or police force concerned, to address the matter and prevent a reoccurrence of the matter.
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.
In this case we identified the following areas for improvement.
IOPC reference
Recommendations
The IOPC recommends SWP take steps to ensure police officers and custody staff are supported to identify and interact with people who have neurodiverse needs, including those with autism spectrum conditions. This should include consideration of the training and guidance officers and custody staff receive on neurodiversity and best practice on interacting with people who have neurodiverse needs.
Accepted:
A working group has been created as a directive from the strategic lessons learned group.
The working group is led by Custody Services, Superintendent Karl Eenmaa and consists of Chief Inspectors or equivalent representatives from Custody, PPU and Learning and Development.
The working group is currently progressing work in relation to:
• Identifying the availability and provision of neurodiversity training within the organisation and any additional training needs.
• Environmental changes that may be considered in the custody environment, to comply with best practice around custody estates and neurodiversity needs
• Communications issued to custody staff, officers and healthcare practitioners around identifying neurodiverse needs and allocation of AA if required
• Communications issued to Custody Staff, officers and Healthcare practitioners around identification of medication recording in property and earlier access to HCP
• Refreshing the crime before capacity messaging.
These are longer term pieces of work with an update on progress expected at the next meeting in March 23.
The IOPC recommends SWP consider how the custody environment can best support detainees with neurodiverse needs. This should include consideration of what adjustments can be made to the custody estate to achieve this.
Accepted:
A working group has been created as a directive from the strategic lessons learned group.
The working group is led by Custody Services, Superintendent Karl Eenmaa and consists of Chief Inspectors or equivalent representatives from Custody, PPU and Learning and Development.
The working group is currently progressing work in relation to:
• Identifying the availability and provision of neurodiversity training within the organisation and any additional training needs.
• Environmental changes that may be considered in the custody environment, to comply with best practice around custody estates and neurodiversity needs
• Communications issued to custody staff, officers and healthcare practitioners around identifying neurodiverse needs and allocation of AA if required
• Communications issued to Custody Staff, officers and Healthcare practitioners around identification of medication recording in property and earlier access to HCP
• Refreshing the crime before capacity messaging.
These are longer term pieces of work with an update on progress expected at the next meeting in March 23.
The IOPC recommends SWP take steps to ensure custody staff, in particular custody officers and healthcare professionals, understand when detained persons require an
Appropriate Adult. This should include consideration of:
1. Issuing communications to custody officers reminding them when a detainee should be treated as vulnerable and therefore requires an Appropriate Adult.
2. Providing refresher training on the legislation and national guidance regarding the provision of Appropriate Adults.
Accepted:
A working group has been created as a directive from the strategic lessons learned group.
The working group is led by Custody Services, Superintendent Karl Eenmaa and consists of Chief Inspectors or equivalent representatives from Custody, PPU and Learning and Development.
The working group is currently progressing work in relation to:
• Identifying the availability and provision of neurodiversity training within the organisation and any additional training needs.
• Environmental changes that may be considered in the custody environment, to comply with best practice around custody estates and neurodiversity needs
• Communications issued to custody staff, officers and healthcare practitioners around identifying neurodiverse needs and allocation of AA if required
• Communications issued to Custody Staff, officers and Healthcare practitioners around identification of medication recording in property and earlier access to HCP
• Refreshing the crime before capacity messaging.
These are longer term pieces of work with an update on progress expected at the next meeting in March 23.
The IOPC recommends SWP take steps to ensure that when a detainee is brought into custody:
1. the custody officer makes sure appropriate enquiries are undertaken to confirm whether the detainee has any medical conditions and, if so, whether
the detainee is taking any medication for these conditions.
2. the custody officer makes sure appropriate enquiries are undertaken to confirm when the detainee is next due to be administered their medication;
And:
3. information about when a detainee is next due to be administered their medication is recorded and shared with the custody officer and relevant
healthcare professional.
Accepted:
A working group has been created as a directive from the strategic lessons learned group.
The working group is led by Custody Services, Superintendent Karl Eenmaa and consists of Chief Inspectors or equivalent representatives from Custody, PPU and Learning and Development.
The working group is currently progressing work in relation to:
• Identifying the availability and provision of neurodiversity training within the organisation and any additional training needs.
• Environmental changes that may be considered in the custody environment, to comply with best practice around custody estates and neurodiversity needs
• Communications issued to custody staff, officers and healthcare practitioners around identifying neurodiverse needs and allocation of AA if required
• Communications issued to Custody Staff, officers and Healthcare practitioners around identification of medication recording in property and earlier access to HCP
• Refreshing the crime before capacity messaging.
These are longer term pieces of work with an update on progress expected at the next meeting in March 23.
The IOPC recommends SWP consider using this incident as an anonymised case study to promote learningamong officers. This should include consideration of:
1. how officers responded to this incident;
and 2. explore (drawing upon best practice) what alternative actions could be taken to achieve the best possible outcome when officers respond to similar incidents in the future.
Accepted:
A new officer safety training scenario has been prepared and delivered. The scenario which utilises the principles of LEAPS and BUGEES is designed to assist officers in communicating with an individual, who is, or may be neurodivergent. The officers response to the scenario impacts on the outcome allowing officers to explore communication techniques and reflect.
This new scenario was introduced in January 2022 and has been well received.