Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, June 2022
In June 2022, Hampshire Constabulary officers responded to a request from Hampshire Fire and Rescue to attend a home address of a woman who was suspected of initiating the fire.
Officers transported the woman to hospital after she disclosed she had taken a number of pills. Once medically discharged, the woman was transported to Basingstoke Custody Suite, where her detention was authorised.
The custody record showed the woman had a previous self-harm attempt in custody and self-harm warning markers on her Police National Computer record.
The woman was booked in on a level one general observation, where officers would check on her every 30 minutes. During her detention, the woman made attempts to self-harm and was detained under the Mental Health Act.
The woman had inflicted a serious self-injury and was transported to hospital with suspected nerve and soft tissue damage. Whilst at hospital, medical staff conducted a mental health assessment.
We specifically investigated the risk assessments carried out and decisions made during the woman’s detention. We investigated the quality and frequency of the cell checks and the actions taken she was discovered with injuries.
Our investigators interviewed two police officers and one police staff member. During the investigation, a number of witness statements were taken from police officers, police staff and the mental health care professional.
We reviewed CCTV and body worn video footage and analysed the 999 call. We reviewed other evidence including the woman’s medical documentation.
During the investigation there was an indication that two police officers and one police staff member had behaved in a manner that would justify the bringing of disciplinary proceedings or had committed a criminal offence.
Our investigation concluded in June 2023. We waited for associated proceedings.
We concluded there was no indication that there was no indication any police officer or staff member behaved in a manner that would justify disciplinary proceedings or had committed a criminal offence.
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 key areas for national improvement.
Of note, we recommended that the Ministry of Justice should remove the sharp edges of metal rebate strips on custody cell doors during construction. In addition, we recommended that the National Police Chiefs’ Council shares our learning from this investigation with all force custody leads, encouraging them to take necessary steps to address concerns.
IOPC reference
Recommendations
The IOPC recommends that the Ministry of Justice (MOJ) amends the Police Custody Suites Design Guide to reflect that any sharp edges on metal rebate strips (also known as rectification strips) fitted to custody cell doors should be removed during construction and inspection to lessen any risk of self-harm.
This follows an IOPC investigation into a near-miss in custody. A detainee was placed in a custody cell [redacted] [and made an] attempt to harm themselves.
Following the incident, remedial works were conducted on cell doors containing the rebate strips at the custody suite where the incident took place and the NPCC circulated a force-wide notification to custody leads asking them to consider checking any rebate strips – widely fitted to custody doors to minimise ligature risks – and removing the edges where necessary to lessen the risk of a similar incident reoccurring. A review of the existing Police Custody Suites Design Guide showed that it did not contain specific reference to ensuring that sharp edges on rebate strips were removed to lessen any self-harm risk during construction or inspection.
Recommendation accepted:
Additional guidance has been added to:
Police Custody Suites Design Guide
Standard Number STD/Z/DG/078
Issue 003 – Publication Date: 06/02/2023
Section 8.11.4 Cell Door
New text added (as bold underlined):
“The cell door frame should be fitted with a removable and adjustable door keep. This will allow the door to be quickly opened should the lock jam and allows the tolerance fit against the rebate to be adjusted. The tolerance between the cell door and rebates (from the cell side) is critical and should be within the advised limit of 2mm and be capable of adjustment as required during the operational use of the cell in years to come. The gap between the bottom of the door and floor should be a maximum of 10mm. It is important that the inner (cell-side) face of the door, frame and rebate strip are carefully inspected for any sharp edges or angles that a detainee might use to cut or abrade materials or themselves and that any such edges are removed.”
Section 18.5.14 Custody suite inspections prior to practical completion
Text added to checklist (as bold underlined):
“Typical checklists: Each force should maintain a checklist of features to be inspected.
- Cell doors – particular attention to be given to max gaps [2mm] at door stops & hatch, [10mm] between door and floor, sharp edges on rebate strips or other components”
The IOPC recommends that the National Police Chiefs Council (NPCC) shares the learning from this IOPC investigation with all force custody leads, asking them to take steps to ensure metal rebate strips (also known as rectification strips) fitted to cell doors are reviewed as part of regular checks conducted in custody suites to ensure there are no self-harm risks. This is due to the possible degradation of these strips over time which increases the risk for self-harm.
This follows an IOPC investigation into a near-miss in custody. A detainee was placed in a custody cell [redacted] [and made an] attempt to harm themselves.
Following the incident, remedial works were conducted on cell doors containing the rebate strips at the custody suite where the incident took place and the NPCC circulated a force-wide notification to custody leads asking them to consider checking any rebate strips – widely fitted to custody doors to minimise ligature risks – and removing the edges where necessary to lessen the risk of a similar incident reoccurring. Custody leads were not asked to conduct these checks regularly.
Accepted:
This learning recommendation will be circulated on ChiefsNet for all Chief Constables to consider for wider learning. It will also be shared with Criminal Justice and Custody Leads nationally whose details are held by the NPCC Custody Portfolio.
The IOPC recommends that the National Police Chiefs Council (NPCC) shares the learning from this IOPC investigation with all force custody leads, asking them to take steps to ensure custody staff understand the ligature risk associated with plimsolls provided to detainees. Where a detainee is assessed as being at current risk of self-harming, any mitigation to the risk associated with this type of footwear should be proportionate while maintaining detainee dignity as far as is possible.
This follows an IOPC investigation into a near-miss in custody. A detainee was placed in a custody cell [redacted] [and made an] attempt to harm themselves.
The NPCC circulated a force-wide notification to custody leads and the Prisoner Escort and Custody Service (PECS) highlighting the circumstances of this incident and the risk associated with these plimsolls. PECS then shared this notification with two private security companies holding contracts for the North and South of England. It was brought to the IOPC’s attention that in April 2017, a warning notification had been sent to all forces by a different force, following a similar near-miss incident [redacted].
Accepted:
This learning recommendation will be circulated on ChiefsNet for all Chief Constables to consider for wider learning. It will also be shared with Criminal Justice and Custody Leads nationally whose details are held by the NPCC Custody Portfolio.
The IOPC recommends that Hampshire Constabulary takes steps to ensure the microphones covering the booking in desks are in good working order, to ensure information communicated at the booking in desks is audibly captured. In addition, the force should review procedures in place to ensure that the microphones within custody suites are tested on a regular basis and are in good working order.
This follows an IOPC investigation into a near miss in custody where a CCTV camera covering a booking in desk in Basingstoke Custody Suite was of poor audio quality, therefore information communicated during the booking in process was inaudible. Poor quality audio undermines the ability to identify, review and scrutinise important information, in particular information conveyed during an initial risk assessment.
The College of Policing Detention and Custody APP, states, ‘Custody managers should establish an inspection regime for the CCTV system, including both the hardware and software, to ensure the suitability of images. They should also check recording quality.’
A review of Hampshire Constabulary’s current CCTV Standard Operation Procedure showed that custody staff are responsible for ensuring the CCTV system is in working order. Consultation with the force’s custody management team informed of a daily process for checking the working order of the CCTV cameras but not a process for checking the suitability of the microphones.
Accepted:
Hampshire and Isle of Wight Constabulary accepts this recommendation.
The custody department arranged through our Security Systems Technical Officer to have all microphones covering the charge desk areas tested in order to ensure they accurately record the conversation between the custody staff and detainee. The positioning and sensitivity of the microphones will be adjusted to ensure that interactions with the detainee are accurately recorded at the charge desk. However, it should be noted that the microphones are multi-directional so will pick up surrounding sound and cannot be ‘aimed’ at specific areas.
Routine testing of the charge desk audio recordings has been added to the regular planned maintenance of the CCTV systems.
The testing has identified that as the microphones are designed to pick up the loudest noise they sometimes record sounds from behind the booking in desk. The custody department are continuing to work with the manufacturer to ensure the system fitted in our Basingstoke and Portsmouth custody centres is as effective as it can be (Southampton and Newport have different systems). The issue has been added to the custody risk register and progress is being tracked accordingly.
The IOPC recommends that Hampshire Constabulary ensure that Police Constables who provide cover in custody receive custody-specific training so that they have the appropriate level of knowledge and skills to competently perform their role.
This follows an IOPC investigation into a near miss in custody, where a Police Constable (PC) provided Detention Officer (DO) cover in Basingstoke Custody Suite, due to a shortfall of custody staff. The PC had limited experience of working in the custody environment and had not undergone any custody specific training. This meant the custody officer could only allocate the PC to complete cell checks as other roles required particular training or access to specific systems. The PC had to be shown how to complete cell checks and how to use the custody computer system.
The investigation found that there is a practice in the force of using PCs to provide cover for DOs. Information from a Hampshire Constabulary Inspector referenced that, although PC stand-ins provide positive assistance to staffing numbers, they are not routinely exposed to custody as part of their training and are not as competent in the role and aware of the risks in custody as a fully trained DO. A statement from the PC who provided DO cover highlighted that, she did not feel well equipped to perform her role due to insufficient training on how to manage risks in the custody environment.
The Detention and Custody Authorised Professional Practice states that police forces should ensure that those working in the custody environment understand their roles and responsibilities, and that all staff must be trained and competent to perform their role in custody. Additionally, HMICFRS’s custody inspection of Hampshire Constabulary in 2012, recommended that the force ensure PCs who provided cover for DOs receive custody-specific training.
Accepted:
Hampshire and Isle of Wight Constabulary accepts this recommendation.
A guide that covers expectations of the detention officer core role has been written and is now provided to all police officers asked to perform custody duties, and is available to view via the force intranet. Custody Officers have been given the direction to ensure police officers performing custody duties are adequately briefed and directed to read through this document at the commencement of their duty. The officers sign to acknowledge receipt and understanding of the information.