Man sustained a serious injury while in custody – Cleveland Police, August 2019
On 21 August 2019, Cleveland Police officers arrested a man and took him to
hospital where he received treatment for an injury to his arm and a mental health
assessment. The man was taken from hospital to a custody suite where he was
detained. During his detention, the man self-harmed and opened the wound on his
arm using his teeth and a small piece of metal. He also suffered from chest pains
while in custody and was taken back to hospital by ambulance.
Following a Death or Serious injury referral by Cleveland Police, we determined that
the incident should be subject to a local investigation. After reviewing the local
investigation report, we identified potential conduct and therefore invited Cleveland
Police to make a conduct referral.
On 19 June 2020, we declared an independent investigation. During our
investigation we obtained CCTV footage from the custody suite and the man’s
custody record. Based on this evidence, we identified potential conduct for a custody
officer in relation to the appropriateness of the risk assessment and care plan. We
also identified potential conduct for a detention officer in relation to their response to
the man self-harming in his cell. We obtained witness statements from detention
officers and police officers involved in the man’s detention. We then interviewed both
subject officers under misconduct caution and reviewed their responses against local
and national policies and procedures.
We completed our investigation in January 2021. We were of the opinion, both
subject officers had no case to answer and there were no further proceedings. We
shared our report with Cleveland Police who agreed with our conclusions. We
advised that the detention officer would benefit from additional training to ensure full
awareness of responsibilities and duty of care. We also suggested a form of
management action for the custody officer. They agreed that the detention officer
would benefit from management action but failures involving the custody officer were
organisational and steps were taken in a timely manner to safeguard the man.
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 to prevent a recurrence of similar
incidents. We identified three areas of learning and have progressed these under
Paragraph 28A of the Police Reform Act 2002.
IOPC reference
Recommendations
The IOPC recommends that Cleveland Police should take steps to ensure that custody officers follow Authorised Professional Practice when determining and recording levels of obsevation for detainees. This should include consideration of whether:
- any changes are required to force custody systems (e.g. Niche) so that levels of observations are recorded in line with APP.
- any training, guidance or reminders are needed to ensure custody staff understand APP obervation levels.
- any further monitoring or oversight is required to ensure custody staff adhere to APP observation levels.
This follows an incident where a man self-harmed in custody, removing stitches from an existing inury to his arm. The investigation found that the custody officer placed the detainee on level 3 constant observations with 15 minute rouse and respond checks from the outset although this was not clear from the custody record. The custody officer also recorded on the custody record that the detainee would be going on "constant" due to him self-harming in the cell. However, the detainee was already on level 3 constant observations and would be going onto level 4 close proximity observations. The investigation found that this was not in line with the observations levels defined in APP and that it was not clear what level of observation was required for the man. The investigation found that custody staff within Cleveland Police don't always follow APP in terms of observation levels. By not aligning correctly with APP there could be potential for confusion as to which observation level a detainee is on. As such, there is a potential risk that a detainee may not be monitored at a level appropriate to their risk.
Do you accept the recommendation?
Yes
Accepted action:
Cleveland Police acknowledge that the current practice within custody does not conform to Authorised Professional Practice when determining and recording levels of observations for detainees.
There is a requirement to change Niche to accommodate this. A project has commenced to address the issues raised and the Cleveland Police Niche administrator has been tasked to implement the required changes.
Other Niche users have been approached to understand how they record levels of observation and if they have established a solution to this.
It is estimated that this will be implemented in July 2021.
Continuing Professional Development (CPD) sessions were due to take place in 2020 but were unable to be accommodated due to the coronavirus pandemic. The CPD sessions will now take place week commencing 12th April for all custody staff to attend.
During these sessions training will be provided to all custody staff to ensure they understand APP Levels of Observation.
The monitoring of the observation levels will be part of a performance management framework and will be subject to dip sampling to ensure compliance.
The IOPC recommends that Cleveland Police should review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This should include consideration of;
- the procedures in place to ensure custody staff carrying out CCTV observations are not engaged in other tasks.
- the procedures in place to ensure there are sufficient monitors and staff available so that detainees are safely supervised via CCTV.
This follows an incident where a man self-harmed in custody, removing stitches from an existing injury to his arm. The custody officer placed the man on level 3 observations with CCTV monitoring for self harm and epilepsy.
The investigation found that CCTV operators continue to be given adminstrative tasks and therefore cannot focus solely on monitoring CCTV footage of at risk detainees. However, it is apparent that this practice continues at Middlehaven custody suite. There is also evidence to suggest that the CCTV observations are not always recorded on the custody record. This is not in line with APP.
These issues have previously been raised by the IOPC and the AA responded in August 2020 as follows;
"Cleveland Police have taken steps to resolve this and remove the multi tasking function from the D.O. conducting level 3 constant observation by monitoring CCTV. A review of resourcing and procedures will be carried out to to ensure compliance with APP"
HMICFRS also identified the same issue when they inspected the custody suites in December 2014. HMICFRS recommended;
"There should be sufficient monitors and staff available so that detainees are safely supervised via CCTV; where possible staff carrying out those observations should not be engaged in other tasks.
Do you accept the recommendation?
Yes
Accepted action:
Analysis of demand in custody including where the CCTV operator sits has been conducted. This analysis has identified that detention officers receive approximately 8000 calls per month.
A telephone extension is located in the position where the where the CCTV operator conducts their viewing duties. This extension receives approximately 3000 calls per month.
This has been raised in the departmental senior leadership team meeting as a cause for concern. Work is ongoing between custody and the communications department to establish how this demand can be diverted. In the interim this telephone extension has been moved.
In addition to answering the telephone, the CCTV operator is also required to control access into the rear operational yard and custody suite. This is because the force elected to move away from warrant card access to the rear yard due to misuse of the operational car park. Work is ongoing between custody and the estates department to establish how this demand can be better served.
During an upcoming CCTV replacement within the PFI custody building the placement of the CCTV operator is being amended to ensure the role is segregated of all other responsibilities. To assist an adjustment is required to the current staffing model as a further Detention Officer will be required to work synonymously with the CCTV operator.
The CCTV upgrade (from analogue to digital) will improve the quality, ensure compliance with the latest IOPC recommendations (including blind spots) and therefore improve safety.
The IOPC recommends that Cleveland Police should take steps to ensure that all searches in custody are completed to a high standard and that force policies and Authorised Professional Practice (APP) are followed.
This follows an incident where a man self-harmed in custody, removing stitches from an existing injury to his arm. The investigation found that the detention officers carried out a search which did not follow the force's Standard Operating Procedures and APP. This potentially gave the detainee the opportunity to secrete an object which he later used to self-harm with. The search took place in the cell and was not overseen by the custody officer. This was not in line with APP which states the custody officer is responsible for overseeing the search of detainees. Given that the overall responsibility for the care of the detainee lies with the custody officer, it is important that the custody officer adheres to APP, particularly in relation to searches. If a detainee is not approrpriately searched then there is a potential increased risk to the detainee and to custody staff if they have secreted an item.
Do you accept the recommendation?
Yes
Accepted action:
Further training will be provided to detention officers to ensure they understand and comply with Custody APP.
Cleveland Police are in the process of reviewing the role and responsibilities of Detention Officers in custody as they are too frequently required to perform more conventional officer duties such as booking in which can limit their availability for searching. It is preferential that Detention Officers conduct the searching within custody to ensure consistency.
This review will focus on the core function of the detention officers and ensure they are compliant with this function.
Recent guidance has been circulated to all staff regarding the necessity to conduct searches under the supervision of the custody sergeant on every occasion.