Recommendations - Norfolk Constabulary, August 2023
We identified organisational learning from an IOPC review of a death or serious injury. The review related to a detainee's health who had tested positive for drugs and was having difficulty staying awake. On arrival at the police station, he was held in a holding cell for 58 minutes. After his detention was authorised, he became unresponsive and had to be taken to hospital.
IOPC reference
Recommendations
The IOPC recommends that Norfolk Constabulary should take steps to ensure custody practices and procedures regarding detainees who have arrived at a custody suite and are being held in a holding area prior to being booked into custody are in line with PACE Code C and Authorised Professional Practice. In particular, consideration should be given to ensuring that where there are delays in booking in detainees that:
a) Procedures are in place to make sure that detainees being held in holding areas are subject to an ongoing risk assessment.
b) Custody officers triage and prioritise vulnerable detainees to be booked into custody.
c) Detainees have the opportunity, where necessary, to be seen by a healthcare professional (HCP) while being held in a holding area.
d) Arresting or escorting officers constantly monitor the welfare of the detainee until they are brought before the custody officer.
e) Relevant information identified during an ongoing risk assessment or from observations is shared with custody staff and, where necessary, documented in the custody record as soon as practicable.
This recommendation follows a Death or Serious Injury (DSI) report into an incident where a man in custody on suspicion of driving while under the influence of drugs became unresponsive and had to be admitted to hospital. The man appeared to be having increasing difficulty in staying awake.
On arrival at the police station he was held in a holding cell for 58 minutes, during which time he repeatedly swayed, slumped forwards and was very drowsy. It is unclear what information was conveyed to custody staff regarding his condition on arrival, or what efforts were made to triage him to see if he needed to be prioritised to be brought before the custody officer. The officer who remained with the man did not appear to actively monitor him in the holding cell, and they did not document any risk assessment or observations. A healthcare professional was not requested to see him until after the booking process had been completed. At that point, his condition deteriorated and an ambulance was called.
There appears to be a discrepancy between the measures in place to safeguard vulnerable detainees once detention has been authorised and the arrangements in place while they are waiting in a holding cell. This is an area of potential vulnerability for custody suites, which has the potential to contribute to deaths or serious injuries in custody, particularly in a busy custody suite where there can be long waits before detainees are put before the custody sergeant.
Response accepted:
The Appropriate Authority (AA) accepts this recommendation on behalf of Norfolk Constabulary. A review of the force policy document ‘Custody’ and working practices within the Custody setting is currently underway. The head of department for Custody has been furnished with the specifics of this recommendation who will ensure the working practices are updated to reflect the current Authorised Professional Practice & PACE Code C.
Once the Policy is updated, Officers and Staff within the Custody setting will be made aware of the process changes.
The IOPC recommends that Norfolk Constabulary takes steps to ensure that response officers, who come into contact with a person who is believed to have consumed drugs, can recognise the signs and symptoms of toxicity for commonly encountered drugs (as set out in Authorised Professional Practice).
This recommendation follows a Death or Serious Injury (DSI) report into an incident where a man in custody on suspicion of driving while under the influence of drugs became unresponsive and had to be admitted to hospital.
The man had been arrested after testing positive for cocaine at the roadside. However, the drug wipe tests used by the force, which can only be administered by specially trained officers, can only identify the presence of cocaine and cannabis. On arrival into custody the man was held in a holding cell for 58 minutes before being booked in and seen by a healthcare professional (HCP).
The way that the man presented was not typical of a person who has only taken cocaine. He was noted to be unsteady on his feet, his speech was slurred and his eyes were glazed. The man also appeared very drowsy, falling asleep intermittently and having to be roused by officers on a number of occasions.
None of the officers who had contact with the man prior to him entering custody appear to have recognised the likelihood that he was also under the influence of an additional substance. This risk factor was not identified until the man was seen by a HCP after the booking in process had been completed.
Response accepted:
The Appropriate Authority (AA) accepts this recommendation on behalf of Norfolk Constabulary. To address this recommendation, we intend to create a bespoke publication to be disseminated to all public facing staff/ officers highlighting the risks associated to persons who have consumed drugs. The purpose of the document will be to ensure officers/ staff can recognise the signs and symptoms of toxicity for commonly encountered drugs. It will also give direction as to how to safeguard and treat persons under the influence of drugs. This will include a reminder of the heightened risk where someone has consumed a combination of drugs. This case will be used as a case study to highlight the consequences of poor safeguarding practices.
The IOPC recommends that Norfolk Constabulary takes steps to ensure that response officers, who come into contact with a person who is believed to have consumed drugs, consider the possibility of whether the person has consumed different drugs. Drugs taken in combination may increase the risk of harm or death and should be considered an additional risk factor that forms part of officers’ decision making.
This recommendation follows a Death or Serious Injury (DSI) report into an incident where a man in custody on suspicion of driving while under the influence of drugs became unresponsive and had to be admitted to hospital.
The man had been arrested after testing positive for cocaine at the roadside. However, the drug wipe tests used by the force, which can only be administered by specially trained officers, can only identify the presence of cocaine and cannabis.
The way that the man presented was not typical of a person who has only taken cocaine. He was noted to be unsteady on his feet, his speech was slurred and his eyes were glazed. The man also appeared very drowsy, falling asleep intermittently and having to be roused by officers on a number of occasions.
None of the officers who had contact with the man prior to him entering custody appear to have recognised the likelihood that he was also under the influence of an additional substance. This risk factor was not identified until the man was seen by a HCP after the booking in process had been completed.
Response accepted:
The Appropriate Authority (AA) accepts this recommendation on behalf of Norfolk Constabulary. As with recommendation 2, this will be addressed by way of a bespoke publication.