Recommendation - South Wales Police, August 2022
We identified organisational learning from a review following a man's detention in custody.
IOPC reference
Recommendations
The IOPC recommends that South Wales Police takes steps to ensure that custody staff are aware of how to safely manage detainees who have sleep apnoea. Consideration should be given to:
- Updating custody policies and procedures to provide clear and accurate guidance on how to manage detainees with sleep apnoea in custody.
- Delivering training for custody staff about sleep apnoea to increase awareness of the condition and how it can be managed in custody.
- Highlighting, through training and guidance, the potential risks associated with sleep apnoea and any machine used to treat the condition. These risks should be considered by custody staff when completing a risk assessment and setting observation levels for a detainee with sleep apnoea.
This follows an IOPC review of a Death and Serious Injury (DSI) local investigation where a detainee's sleep apnoea machine stopped working during their detention. The machine was retrieved from the detainee’s property after they disclosed they had the condition as part of a risk assessment conducted on their arrival in custody; the detainee was also noted as intoxicated and placed on level two observations during this assessment. The detainee was moved to a cell that was situated close enough to a plug to enable the machine to be switched on using an extension cord. Due to lack of experience and/or knowledge of the condition, and such machines used to treat it, police officers and staff conducting welfare checks on the detainee were unaware of the machine malfunctioning. This resulted in the detainee becoming unresponsive and requiring hospital treatment.
South Wales Police does not currently have a policy or training in place regarding sleep apnoea and how it should be managed. The implementation of any policy or training package in relation to the condition should look to incorporate the issues highlighted within this recommendation. This may help to improve detainee (and custody staff) safety and welfare in the future.
Do you accept the recommendation?
Yes
Accepted action:
This recommendation was discussed in the force quarterly Strategic Lessons Learned forum on 16th June 2022.
Following the group meeting it was agreed that the recommendation was accepted and that in future;
- All sleep apnoea cases should be dealt with by means of Voluntary Attendance (VA) unless extreme circumstances. All custody staff were briefed on this.
- Where no other option is available in these extreme circumstances individuals should be constantly monitored whilst in custody.