HMIC/HMIP inspections of custody suites

Report: 12
Date: 8 September 2011
By: Assistant Commissioner Central Operations on behalf of the Commissioner

Summary

This report identifies the systems in place to ensure that custody suites are fit for purpose in line with HMIC/P Inspections and recommendations. It answers the specific questions asked in the commissioning brief relating to the management of custody suites. It also highlights ongoing work and progress within the custody arena.

A. Recommendation

That

1. Members note the responses to questions asked in the commissioning brief which detail ongoing work in custody suites.
2. Members note the significant progress which has taken place within the custody arena following a process of regular inspections, training and policy guidance.

B. Supporting information

The Custody Directorate within the Criminal Justice OCU (TPCJ) has worked to improve safety in custody since its introduction in 2004. In 2007 the Directorate introduced an inspection and compliance process for custody suites. This takes account of the HMIC/P thematic inspection of all places of detention nationally by assisting Borough Commanders to prepare in advance for pre-planned inspections and also for unannounced visits. This process also identifies failures, lessons to be learnt and good practice and includes a process to drive improvement where necessary. This report responds to the specific questions raised regarding such matters in the commissioning brief and also highlights ongoing work aimed at improving standards of care in custody suites.

The corporate and strategic structures in place to ensure record keeping, collation of data, including complaints, and lessons learned.

1. To assist with organisational learning and the safer detention of detainees all incidents which occur within a custody environment, which if allowed to continue to their ultimate conclusion could result in the death, serious injury, or harm to a detainee or any other person, must be reported through our Successful Interventions regime. (See Appendix A)

1.1. Statistics are collated from Form 370C on a monthly basis. These include the summary of the circumstances, latest totals by borough, methods used and any news items are sent out to all Custody Managers, Designated Detention Officers (DDOs), Custody Nurse Practitioners (CNPs) and other appropriate departments within the MPS.

1.2. Twice a year the SI News Letter is published to all relevant areas of the MPS to advertise the latest trends and news items. This is also sent to the Constabularies, National Offender Management Service (NOMS) and National Policing Improvement Agency (NPIA).

1.3. The Custody Inspection and Review Team use the SI data as a tool when identifying which BOCUs to inspect and also to identify if BOCUs have particular areas of concern, which need to be examined during the inspection. The Compliance and Inspection Team also advise BOCUs of HMIC/Ps findings around the taking of complaints and suggest where improvements could be made.

1.4. In January 2008 work from the MPS Inspectorate produced a Corporate Organisational Learning model. Throughout 2008 this was implemented across all MPS business groups. The DPS Prevention and Reduction Team deal with organisational learning following recommendations made by the Independent Police Complaints Commission (IPCC), the National Learning Lessons Committee (membership of this committee compromises of IPCC, Home Office, Association of Police Authorities, HM Inspectorate of Constabularies, National Policing Improvement Agency), Coroners (recommendations made directly to the MPS, and made to other police services as outlined by the Ministry of Justice), DPS Investigators, and Civil Actions Team. (For details see Appendix B)

The measures taken to ensure the privacy and dignity of detainees including communication with solicitors and access to wash hand basins and showers.

2. The long term strategy is to provide the appropriate custody estate to support operational policing. This forms part of the Custody Improvement Project within TP Development. The intention is to provide fewer but larger and modern custody facilities throughout the MPS. A priority list has been devised to highlight areas with the highest need and this has been used to determine the order of progression.

2.1. Telephone facilities at the new build sites are one aspect which has been improved. Each new build cell is fitted with an intercom. The intercom is used by a detainee to talk with custody staff who can forward a telephone call through to the cell. At the start of a call an automated message will be played to both the detainee and the call recipient. This message will explain that the call maybe monitored and the maximum duration of the call. The new build also have wash hand basins with dryers in each cell. Each corridor has a disabled access shower.

2.2. Currently a number of custody suites have had telephones fitted with privacy hoods and this is subject to an ongoing roll out. These hoods allow for a private telephone call between detainees and their solicitor. Where privacy hoods have not yet been installed or where it is impractical due to a lack of space, where possible, telephones are sited away from the custody desk and detainees are able to speak out of earshot whilst still being supervised. Additionally consultation or interview rooms are available within each custody suite to allow for private consultation.

2.3. CCTV in custody - MPS operational custody suites display posters alerting all persons, in the custody suite, to the fact that video and audio recording is in operation. The wording on the posters is simple (“attention video and audio in operation”) and is supported by a picture of a video camera.

2.4. Access to basins and showers
Washing facilities in the form of hand basins and/or showers are available for the use of detainees at all MPS police stations with cells. The MPS Custody Standard Operating Procedure states that if a detainee asks for a shower they must be allowed to have one unless there is a good reason why this cannot or should not happen. Any request and/or any refusal (including the reason(s) for a refusal) must be fully documented in the Custody Record.

2.4.1 In addition Custody Officers should ensure that adequate time is set aside for detainees to wash and clean their teeth (and shave if appropriate) before transfer to court or the business of the day is commenced. All personal ablution items, issued to MPS detainees, are suitable for use by vegan prisoners and members of all faiths.

2.4.2 If a detainee is to be held for an extensive period of time e.g. immigration detainees or others held in excess of 24 hours, and they are at a custody suite that has no showering facilities, if they request a shower they must be moved to a custody suite that has adequate facilities.

2.4.3 Consideration should be given to members of certain faith groups who express a desire to wash before prayers. Although this should not be allowed to interfere with the efficiency of the custody suite, requests of this nature should be accommodated wherever possible.

2.5. Suitable Clothing
If any article of clothing worn by a detainee on arrest is removed for examination or seized as an exhibit, police must ensure that the detainee is adequately clothed when appearing in court.

2.6. The dignity of transvestites and transsexuals commands the same respect and dignity as any other member of the public. The MPS has detailed guidance, issued by the MPS Diversity and Citizen Focus Directorate, around this subject underpinned by general principles.

2.7. General principles include establishing the 'preferred' gender of the detainee being dealt with and what sex they should be treated as. This would include a transvestites/cross-dressers arrested ‘en femme’ should be given an opportunity to remove any make up and to change into clothes different to those that they were arrested in, but with the added sensitivity due to the possibility that the detainee’s family may be unaware of his/her alter-ego.

The measures taken to ensure the appropriate facilities and services are available for detainees with diverse needs such as juveniles, women, disabled, those with mental health issues, those with language issues and detainees with dependents or dependency (carer) concerns.

3. Facilities and services.

3.1. Juveniles
Custody Officer training includes a number of provisions around the needs and requirements of juveniles. All juveniles (a person under 17) in police custody legally require the assistance of an appropriate adult, the provision of appropriate adults other than parents or guardians are arranged by Borough Operational Command Units. Under The Police and Criminal Evidence (PACE) Act there are specific requirements made for juveniles where bail after charge is refused. In these circumstances police must consult with the local authority to seek appropriate accommodation where available. There is also a requirement for an appropriate adult to be present when a juvenile has samples taken; this requirement also applies if a strip search is to be carried out unless there is a risk of serious harm.

3.2. Women
The MPS identified that females will have additional and unique requirements. This led to the creation of a separate question to be asked of females to establish if they wanted to speak to a female member of staff unconnected with the investigation. This provides an opportunity for female detainees to speak to someone on issues such as feminine hygiene which they may, understandably, feel uncomfortable discussing with a male member of staff. Feminine hygiene items are available to cater for the needs of female detainees.

3.3. Disabled Detainees
Part 3 of the Disability Discrimination Act and The Equalities Act 2010 puts a duty on the Metropolitan Police Service to take steps to cater for persons’ detained, responsible adults, solicitors and other visitors that may have a disability and to anticipate what may be required and make all reasonable efforts to remove any physical barriers identified.

3.3.1 It is reasonable to anticipate therefore that the MPS are likely to have visitors to the custody suite with visual or hearing impairments; wheelchairs users; people with learning difficulties and others with a variety of other disabilities.

3.3.2 The custody area has a number of complications, primarily as it relates to the treatment, the rights and liberties of people and not just the physical aspects of the building.

3.3.3 In the light of this a design standard has been produced. This standard takes account of the needs of the detainee and also ensures that custody beyond the cell is accessible, with the provision of fixed induction loops on charge desks and accessible toilets in the charge area. Level access shower areas as well as level access throughout are also included. Some features that would normally apply to accessible areas are however excluded due to custody security. e.g. automatic doors.

3.3.4 All custody suites have had access audits carried out. As a whole and in general terms the majority provided reasonable accessibility because their design already encompassed wide corridors and doors, level access to avoid steps and access ramps. These access ramps in many cases are not compliant for unescorted access; however unescorted access in a custody suite is rare.

3.3.5 Most Boroughs have portable induction loops which are available for custody. These are not provided by property services but are self funded by the BOCU. Many custody suites have fixed loops on charge desks installed although some of these may not comply with current standards.

3.3.6 This coupled with an estate strategy that includes a major change to the way the MPS delivers custody, through large custody clusters, has meant that no wholesale upgrades have been carried out to existing custody suites.

3.3.7 In general, the majority of custody suites are accessible to the majority of disabled people although many are not of a modern design or to the current standard.

3.3.8 The specifications for new custody builds are detailed in the Custody Design Guide (subject to agreed exceptions) which has been developed in line with user consultation. Various aspects of provision for disabled use have been included, e.g. DDA compliant toilets, cells, doorway widths, induction loops. The guide is used as a template in the building of new custody suites. The document is a live document continually updated through a system of formal change control.

3.3.9 The MPS Custody SOP includes guidance around providing assistance through Familiar Personal Assistants to detainees with physical needs such as using the toilet, washing and mobility. The forthcoming updated version of the SOP will include guidance around assistance dogs in custody.

3.4 Mental Health Issues
Detainees who are mentally vulnerable also legally require the assistance of an appropriate adult. Detainees who are identified as having mental health issues are routinely referred to a healthcare professional (HCP). The Custody Directorate has commissioned the University of Newcastle to review the custody risk assessment pro forma to improve the identification of medical and mental health issues.

3.4.1 Revised guidance on the subject of constant supervision of vulnerable and/or self-harming detainees and a supporting DVD has been produced with the assistance of the Centre for Mental Health.

3.4.2 A separate Policing Mental Health SOP has been produced by the MPS Mental Health Project Team, part of which deals with practical issues around detainees with mental health needs.

3.5 Language
Interpreting services are provided to detainees through a number of available resources. In the first instance telephone interpreting is used to assist custody staff in establishing effective communication with regards to non-evidential needs such as conducting risk assessments, reviews and bailing of detained persons. Where the attendance of an interpreter is required all requests are made through the Interpreter Deployment Team who operate a 24/7 service. A project is currently ongoing to create a standalone computer to assist in ‘initial contact’ which would be placed in custody suites and police station reception areas to deal with simple information requests and exchanges.

3.5.1 The MPS Language Programme has since October 2008 been implementing a number of solutions which are aimed at widening and speeding up access for detainees, witnesses and victims within the MPS.

3.5.2 An Interpreter Deployment team has been established at Hendon which has handled 39,000 interpreter deployments during the past year. It has assigned named interpreters 75% of the time within 15 minutes 85% of the time within 30 minutes and 96% of the time within 1 hour.

3.5.3 Telephone Interpreting has been made available to all custody suites in the MPS, including in the healthcare professional room, through bespoke double handset phones installed by our supplier Language Line.

3.5.4 A video conferencing platform is in the process of installation in a selected interview room in all custody suites across the MPS. This will facilitate interpreting provided remotely for both consultations and interviews and thereby remove the requirement for interpreters to travel to the location and consequently speed up access even further. This will be fully installed by the end of 2011.

3.5.5 New scheduling software is in the process of procurement. This will identify the nearest and most appropriate interpreter to the police station requiring interpretation. This will be complete by March 2012.

3.5.6 "Initial Contact" software which will identify a person’s language and any risk to their detention is in the process of procurement and will be in place in every custody suite by Jan 2012.

A Language skills training programme which is designed to assist officers to communicate with the communities they police on their Borough, has recently commenced. All detainees are asked whether they have any caring responsibilities as part of the initial detention procedure. This ensures that action can be taken to obtain assistance for the person being cared for and to allay concerns the detainee may have.

Data on the number of detainees under Section 136 (Mental Health Act 1983) and an overview of how their treatment differs to those detained on suspicion of an offence.

4 In the year April 2009 to April 2010 there were a total of 3442 arrests under section 136 Mental Health Act 1983. Of these only 59 individuals were removed to a police station as a place of safety. Seven of those detained were charged with criminal offences. When an individual held under the Mental Health Act is detained at a police station the treatment they receive will be broadly in line with that experienced by a person detained for an offence, this includes access to meals, medical advice, washing facilities etc.

4.1 Key differences outside the broad general treatment described above, mean that fingerprints, DNA sampling, photographs and drug testing will not apply to someone detained using section 136. Powers to search premises, deny access to telephone calls do not apply.

4.2 A chart detailing the full differences is attached at Appendix C.

An overview of the medical care facilities and services available to detainees.

5 Medical Care and Facilities

5.1 The Metropolitan Police Service employs a multidisciplinary healthcare team, comprised of Forensic Medical Examiners (FMEs) and Custody Nurse Practitioners (CNPs), to provide medical care to detainees. The FMEs have contracts with the MPS for their services and the CNPs are members of police staff. Both the FMEs and CNPs provide medical services in accordance with PACE Codes of Practice.

5.2 FMEs provide healthcare services to all Boroughs which are currently split into 8 areas, which again are split into a total of 15 sub-areas. The CNPs are currently providing healthcare services to 10 Boroughs (Barking and Dagenham, Barnet, Croydon, Islington, Kensington and Chelsea, Lambeth, Lewisham, Newham, Tower Hamlets and Westminster). The CNPs are part of a phased recruitment and deployment plan to all boroughs as part of Project Herald. The phased deployment schedule will be completed by March 2013. Due to the reduced workload on the FMEs as the CNPs are deployed the number of FME sub-areas will be eventually be reduced to 6.

5.3 Each custody suite has a dedicated healthcare professional’s room for the treatment of detainees. The room is kept and stocked in accordance with the ‘Safer Detention and Handling of Persons in Police Custody’ national guidance to ensure the safe treatment of persons held in custody. If the detainee is too seriously injured or ill they are transferred to a more appropriate healthcare setting (e.g. A&E). A process is in place for all those that are transferred for the appropriate healthcare information to transfer with them. A form 170 is completed at the custody suite before transfer, and again at the hospital before transfer back to custody.

5.4 Heads of profession have been appointed for each strand of medical care delivery, a Medical Director for the FMEs and a Nursing Director for the CNPs. The introduction of these positions has enabled the implementation of greater governance of clinical practice and performance. A clinical incidence reporting system has been introduced to learn from issues arising and ensure safe practice is implemented. A number of local partnerships, working relationships and information sharing agreements have been developed with NHS trusts to ensure that the detainees that require it are referred to the appropriate care pathway.

An overview of plans to ensure custody staff remains a dedicated, trained and adequately supported resource.

6 The Custody Improvement Project under the TP Development Programme is seeking custody service improvements and efficiencies. The project has explored all aspects of custody service delivery and has made recommendations that are to be considered by TP and CO Chief Officer Groups and Governance Board. These include; ensuring that the service provision is better aligned to MPS demand rather than each BOCU trying to manage demand locally; better utilisation of the estate through a centralised custody suite cell allocation process; staffing better aligned to demand; and officers/staff in supervision and support roles being given sufficient time to undertake the required functions. Further details of the proposals have been provided to the MPA Estates Panel but some of the information in that briefing is not suitable for wider circulation at this time as it is not yet approved through MPS governance routes. Whilst there are no planned staff redundancies (in fact there is proposed continued growth in both DDOs and Nurses), there are some proposed changes to working practices that will affect staff. These have been discussed with staff associations and unions but have not yet been formally communicated to those affected staff.

6.1 The business case is being reviewed at TP Chief Officer Group on Monday 27th June 2011. Following this the business case is due at Governance Board (previously Management Board) on 19th July 2011. If the programme is signed off the project will move into implementation with a timeline yet to be established. The CIP is currently running a shared services custody pilot in Merton and Sutton BOCUs. This has seen Merton Borough close its custody facility and share the larger 30 cell complex at Sutton. Merton have provided custody staff and CPU staff who have been posted to Sutton in order to provide joint, augmented resources to deal with the increased demand at the Sutton suite. A second pilot is in the planning phase for Newham, Waltham Forest and Barking. This pilot has not been signed off by Programme Board but it is hoped this will start in September 2011.

An overview of processes and training for the taking and storing of DNA samples.

7 The MPS have a detailed policy on sampling of persons in custody, and have also published guidance documents detailing the procedure, which includes the collection, storage and subsequent processing of PACE samples. In addition to this SCD4 DNA Unit also provide training for all DDOs on the correct sampling and storage of PACE samples taken from detainees. All police officers, including MSC officers, receive training in the legislation and the practical procedures to take DNA during their initial foundation training. SCD4 are currently in the process of reviewing the sampling procedure which will involve the dissemination of reference materials which may include communications and posters for personnel within the custody environment on correct procedures. SCD4 has a designated Borough Forensic Manager who is currently leading on this review, evaluating and addressing non-compliance on taking DNA samples. The SCD4 DNA Unit currently identifies any sampling failures on a monthly basis. This information is circulated via Performance Information Bureau to all Borough Commanders.

7.1 An Extract from the MPS DNA Standard Operating procedure which provides an overview of the processes for taking and storing DNA samples can be found at Appendix D.

The monitoring and evaluation processes in place to ensure adherence to guidelines on risk assessment of detainees, pre-release risk assessments and the taking and storage of DNA samples.

8 Inspections

8.1 The Custody Directorate has regular contact with the IPCC, HMIC/P and the NPIA to ensure that all relevant information with regards to safety and risk management is disseminated. The Directorate has sought to assess and improve delivery of and compliance with legislative and policy requirements, at a BOCU level, by introducing an internal supportive inspection process in early 2007 - the Inspection & Review Team. This process was created to identify both weaknesses and localised good practice and to instil the ethos of safer detention. The information gathered during the process is fed back to the BOCU, so that command teams can better identify and address any risks that may exist and also appreciate good working practices. Support is given to the borough by agreeing an action plan. The team monitors the borough’s adherence to the action plan through the use of intrusive dip-sampling of custody records and other relevant performance indicators. The Inspection and Review Team has evolved, from one inspector to its current make-up of a strategic lead (DCI), a tactical implementation lead (inspector), and the tactical implementation team (one PS & one Band D).

8.2 Compliance will ensure a corporate approach to the care provided to detainees, ensuring staff have been trained efficiently and that appropriate management and reporting systems are being adhered to. The inspection process is part of a wider overall approach to improving performance and the identification and management of risk. The aim organisationally is to reduce deaths, adverse incidents and complaints.

8.3 Following on from the HMIC/P inspection program, the team have taken responsibility for creating an HMIC/P Recommendation Action Plan and the internal quality assurance (QA) process has allowed the MPS to learn from and implement recommendations that have been made during the HMIC/P’s program of inspections. The action plan ensures that all HMIC/P recommendations are identified and actions carried out by the relevant organisational business leads. Other Force’s recommendations have also been included, to capture any learning gained from their inspections.

8.4 The Inspection and Review Team’s aim is to be as proactive as possible and so help to ensure that the MPS is corporately prepared for any future HMIC/P inspections. To these ends the team have set up a pre-HMIC/P (where announced) inspection process. This provides support to the BOCU at all levels of custody management. It allows the team to ‘health check’ the BOCU and help the BOCU command team to put in place systems and practices that will improve their performance when inspected against the HMIC/P’s expectations.

8.5 The Inspection and Review team have developed and maintained strong links with the HMIC/P team, assisting them wherever possible. In doing so, it ensures that the MPS are as well informed as possible around arising issues and can take measures to address them. Such relevant information is then cascaded out to all custody management, across the MPS.

8.6 The Custody Inspection and Review Team has responsibility for monitoring Borough Operational Command Units (BOCUs) conformity in respect to the implementation and continued compliance to the SOP for the Handling and Storage of Frozen Exhibits and Samples within Operational Command Units.

The provision of suitable storage facilities (‘fridges and freezers) for DNA samples – an update.

9 Following a considerable delay, due to funding issues and sourcing freezers of the appropriate specifications detailed in the SCD4 Standard Operating Procedures (SOP), there was a need to revisit borough requirements for freezers. This was necessary due to changes to the MPS estates which have occurred over the past 12 months.

9.1 This process is almost complete and it is expected that the full order to meet all Borough requirements will be placed through MPS Facilities Management by 30th June. The approximate cost of this including removal of old fridges is £150,000.

Corporate Manslaughter and Corporate Homicide Act 2007

10 The Corporate Manslaughter and Corporate Homicide Act 2007 came into force in April 2008. It creates the criminal offences of Corporate Manslaughter and Corporate Homicide. It applies to all corporate bodies and specifically includes police forces within the definition of a corporation.

10.1 The specific liability under the act in respect of deaths in police custody was delayed for three years in order to provide police services time in which to ensure that the National Guidance on the Safer Detention and Handling of Persons in Police Custody (2006) (“the National Guidance”) was reflected in their policies and procedures.

10.2 It is anticipated that this legislation will apply to police custody from September 2011.

10.3 An organisation will commit corporate manslaughter if the way its activities are managed or organised, including a substantial contribution by its “senior management”, causes a death and amounts to a gross breach of a relevant duty of care owed by the organisation to the victim. The offence of manslaughter by gross negligence, as it applies to companies, has been abolished.

10.4 The new offence cannot be committed by individuals although they can still be prosecuted for gross negligence manslaughter as principal offenders under existing legislation.

10.5 The Custody Directorate has worked to improve safety in custody since its introduction in 2004. Appendix E provides an executive summary of the actions taken in respect of custody issues which are likely to be considered within the context of the Corporate Manslaughter and Corporate Homicide Act. These have already been subject to close scrutiny in settings including several inquests, IPCC investigations and inspections by the HMIC.

10.6 A number of initiatives are being considered at senior level to enhance organisational performance in these areas and colleagues are currently being advised of the impending application of this legislation into police custody.

Additional ongoing work within the Custody Directorate.

11 The Custody Directorate is currently undertaking the following work:

11.1 Working in partnership with Professor Don Grubin, an expert in risk assessment from Newcastle University, to improve the way in which risk assessment information is obtained from detainees during the initial risk appraisal.

11.2 Working with Lambeth NHS to improve the identification and treatment of detainees with mental health issues.

11.3 Working with the MPA to introduce the role of Familiar Personal Advocate to enhance communication with detainees.

11.4 Contributing to the Detention Command Project to improve the central control of custody. This will drive performance and address the gap between strategic intention and tactical delivery identified by the IPCC, HMIC etc.

11.5 Participating in an ACPO Diamond Group, which provides an overview of all Gold Group activity in relation to deaths in police custody and following police contact. The purpose of this group is to identify areas of leaning and issues for the MPS surrounding these deaths.

11.6 Working with the London Ambulance Service to optimise the service provided to custody suites.

11.7 Attending and contributing to the working group currently revising the ACPO Safer Detention and Handling of Person in Police Detention Guidance

12 Improving the level of staff training:

12.1 The introduction of version control and strict attendance records has ensured that the MPS can demonstrate that all custody staff are trained appropriately. Recent training programmes have included a comprehensive Gaoler package and e-learning for all staff carrying out this role. Focus Days and briefings have been given on the requirements of Code C Annex H of the Codes of Practice relating to the observation of vulnerable prisoners. These include DVD’s on the 4 R’s and Constant Supervision created by the Custody and Criminal Justice Directorate.

12.2 The Custody Directorate also assisted the NPIA in drafting the national safer detention learning programme for custody officers based on MPS and GMP courses.

12.3 A regular newsletter is produced and circulated within the service and other police services and partner agencies which disseminate successful interventions and near misses to ensure learning takes place from such incidents.

C. Other organisational and community implications

Equality and Diversity Impact

1. Guidance for the management of custody suites and detainees is contained in The Police and Criminal Evidence Act 1984 Codes of Practice, the Home Office Guidance for the Safer Detention and Handling of persons in Custody Guidance and the MPS Custody Policy. Each of these documents identifies equality and diversity issues and provides guidance on the treatment of individuals. (See also answer to question 3 above). This report contains no further implications which impact these issues.

Consideration of Met Forward

2. This report supports various strands of Met Forward. The work of the Inspections and Review team supports the Met Standards strand by ensuring boroughs are held to account in delivering an effective and efficient custody suite, Met People by ensuring training in custody is fit for purpose and up to date, and Met Specialist by supporting Borough Commanders in delivering a professional and specialist custody service.

Financial Implications

3. There are no financial implications in this report. Any costs associated with changes to the Custody Suites within the MPS will be included in the Custody Improvement Business Case.

Legal Implications

4. The statutory framework for legal compliance is dealt with in the report and no legal issues arise.

Environmental Implications

5. There are no significant environmental implications contained in this report.

Risk (including Health and Safety) Implications

6. The Corporate Manslaughter and Corporate Homicide Act 2007 came into force in April 2008. It creates the criminal offences of Corporate Manslaughter and Corporate Homicide. It applies to all corporate bodies and specifically includes police forces within the definition of a corporation.

6.1. The specific liability under the act in respect of deaths in police custody was delayed for three years in order to provide police services time in which to ensure that the National Guidance on the Safer Detention and Handling of Persons in Police Custody (2006) (“the National Guidance”) was reflected in their policies and procedures. This was negotiated by the ACPO lead for custody in 2008, as it was recognised that police services were unlikely to be able to defend actions under this legislation if they were not compliant with the National Guidance. The significant changes for all forces as a result of the National Guidance had originally been intended to be implemented over a three year period from its introduction in 2007.

6.2. It is anticipated that the custody provision of this act is now likely to come into force in September 2011. The work of the Custody Directorate has ensured that the National Guidance is enshrined in custody policy and an inspections process is in place to ensure compliance with policy. The Custody Directorate has formed a Corporate Manslaughter Oversight Group - the aim of the group is to provide clear and unambiguous strategic intent and tactical delivery to mitigate any risks.

6.3. In support of this the Custody Directorate is preparing a service-wide communication strategy to ensure all members of staff are aware of the change and how their individual roles and responsibilities relate to the custody provision of the Act. Additionally the Directorate are now participating in a Diamond Group chaired by DAC Kavanagh which will maintain an overview of all Gold Groups relating to deaths in or following police custody and identify areas of learning and any issues for the MPS.

D. Background papers

• Policing Mental Health SOP

D. Contact details

Report author: Superintendent Annette Wightman (Head of MPS Custody Directorate)

For information contact:

MPA general: 020 7202 0202
Media enquiries: 020 7202 0217/18

Appendix A: Successful Interventions

To assist with organisational learning and the safer detention of detainees all incidents which occur within a custody environment, which if allowed to continue to their ultimate conclusion could result in the death, serious injury, or harm to a detainee or any other person, must be reported on a Form 370C. This includes incidents from the point of arrest and any unforeseeable event within the custody environment. Form 370C can be completed by any member of staff; the Custody Officer at the time of the incident will be consulted if appropriate. The Form 370C is submitted to the local Borough Custody Manager to quality control the report and for the inclusion of any borough actions and organisational learning. Copies are also sent to the local Police Federation, Police Staff Union Safety Representative and the local Safety and Health lead. If the incident has involved an arrested person their PNC record is updated immediately with the risk details to assist with their future management.

The completed Form 370C is then submitted, by the local Custody Manager, to the Custody Directorate within 10 days of the incident.

When the Form 370C is received by the Safer Detention Team, the details will be entered onto the MPS Successful Intervention (SI) data base. At this stage the details will be 'sanitised' and will exclude all references to any person or details of the borough involved. The team will then check the Form 370C with reference to the NSPIS entry and glean any organisational learning which will then be forwarded to the appropriate department e.g. training / Property Services / Forensic Health Services / Health & Safety etc.

Appendix B: DPS Prevention and Reduction Team – Learning Recommendations

Learning recommendations are dealt with at a number of different levels. Learning at an individual level is forwarded to the individual’s line manager to be dealt with in an appropriate manner by that line manager. Similarly Local or SMT learning is sent to the Operational Command Unit Chief Superintendent to be implemented. Both are logged and 'keyworded' for the Organisational Learning database in order to allow developing learning trends to be identified, and if necessary, escalated to a full organisational learning case. No other action is taken by the Organisational Learning Team in respect of these. Wider Organisational Learning recommendations which may impact in a number of different MPS business areas are, after logging and ‘keywording’, dealt with directly through the DPS Organisational Manager- Prevention and Reduction Team. In each case DPS Organisational Learning Manager (OLM) receives a Learning Case comprising one or more recommendations, with any attached case files and documentation. This is recorded and given a unique case number. A case assessment is then made of the recommendation. This requires a review of previous and current ongoing work on existing recommendations to ensure any case links are identified. The OLM will then identify the area(s) of MPS business affected by the recommendation, and individuals with authority to “make decisions” around the recommendations. The recommendation case is then sent to them. They are requested to review the recommendation and make a decision regarding the implementation of the recommendation. DPS do not make the decisions regarding the recommendations as the policies and resources of other business areas are outside DPS control. The OLM maintains records of all these learning recommendations and decisions and provides statistical information regarding emerging trends. The system is also utilised to implement identified good practice in a similar way.

In summary, the emphasis is on promptly deriving general lessons from specific cases, and ensuring that this learning is then disseminated to the most appropriate audience across the organisation, through direct contact with decision makers on a recommendation by recommendation basis. This is complemented by the intelligence-led 'awareness' presentations developed and delivered by Organisational Learning.

Appendix C: Differences between detention under Sec 136 Mental Health Act and detention for an offence.

Appendix D: The taking of samples is governed by sections 62 and 63 of PACE. Guidance on those provisions is available on the Police National Legal Database (PNLD), the Operation Emerald intranet site or from the Custody Directorate.

The DNA sample taken under these provisions will be in the form of:

• Non-intimate
• Buccal (mouth) swabs (the preferred option)
• Hair; or
• Intimate
• Blood.

It is the responsibility of the Custody Officer to ensure that any sample from a detained person is taken legally.

Actions by officer / police staff taking sample:-

All DNA samples from persons who are in detention following arrest for a recordable offence will be taken using a PACE DNA Sampling Kit. This sample can be used for evidential comparison work if required.

If a DNA sample may be required for evidential comparison purposes relating to the offence for which the person has been arrested a PACE sample must be taken. Sample taken for this purpose should be clearly marked 'Evidential'.

Before taking a PACE sample where an evidential comparison is not required, a PNC check will be carried out on the person. If the person has a PNC record with a 'DNA Confirmed' or 'DNA Profiled' marker, there is no need to take a PACE sample. If the person does not have a 'DNA Confirmed' or 'DNA Profiled' marker, a sample will be taken using a PACE kit, following the instructions enclosed within the sampling kit.

Immediately after sampling, the officer / police staff member taking the sample will carry out a quality control check of the PACE DNA form on the following details to ensure it has been completed correctly:

• Sample number written under the barcode sticker
• Phoenix Arrest Summons number correct (if known at the time of sampling – if not write the number on the DNA form at a later stage)
• Custody Number correct
• Surname correct (if this changes after sampling, ensure PNC Bureau enters the alias on PNC and show the correct details on the DNA form)
• Forename(s) correct (see above)
• Date of birth correct (not current year)
• Sex box correctly ticked
• Ethnic appearance box correctly ticked
• Sample type box correctly ticked
• Date sample taken correct
• Resample box correctly ticked
• Force / station code correct
• Officer taking sample correct (warrant [not shoulder] number to be used)
• Offence type box correctly ticked (one only)
• Exhibit Number correct
• Police Reference correct

The officer / police staff member will carry out a quality control check on the following aspects of the sample to ensure it has been correctly taken:

• Barcodes on tubes, PACE DNA form and spare barcodes match
• Each tube contains one swab
• Swabs not upside down
• Tubes sealed
• Tubes undamaged
• Tubes in inner bag
• Inner bag sealed
• At least 10 hairs with roots (hair cases only)
• Hairs fully inside inner bag (hair cases only)
• PACE DNA form, samples in inner bag and spare barcode sheet enclosed in outer bag
• Tamperproof seal not showing "VOID"

The officer / police staff member will place the sealed sample in the freezer provided for the storage of DNA samples.

Appendix E: Corporate manslaughter and custody - action by the Custody Directorate

The Custody Directorate has worked to improve safety in custody since its introduction in 2004. This document summarises the actions taken in respect of custody issues which are likely to be considered within the context of the Corporate Manslaughter and Corporate Homicide Act. These have already been subject to close scrutiny in settings including several inquests, IPCC investigations and inspections by the HMIC. A summary of the work within the MPS and the national impact is given under each heading.

Safer detention guidance used as a benchmark

MPS

The Custody Directorate conducted a capability assessment and implementation 2007-2009 into MPS policies and procedures, in particular the Custody Standard Operating Procedure (SOP). Outstanding recommendations are issues which affect police services throughout England and Wales. For instance, the NPIA is leading on discussions to formulate protocols between police and healthcare services (NHS and ambulance services). The commissioning and design of detainee transport is also being led nationally.

National

The Custody Directorate actively participated in the drafting of the National Guidance on the Safer Detention and Handling of Persons in Police Custody (2006) by the NPIA (introduced in advance of the Corporate Manslaughter and Corporate Homicide Act becoming law to give guidance to forces) and is now contributing to the first revision.

Improving communications between organisations

MPS

The Custody Directorate introduced the Safer Detention Working Party in July 2005 combining the Deaths in Custody and Medical Care working parties. This provides a multi-skilled strategic forum to develop policy and guidance aimed at preventing deaths and incidents in custody. It provides a direct link to demonstrate corporate learning from ACPO, IPCC, and NPIA etc. Representatives include all relevant internal departments (DLS, First Aid, FMEs, DPS, Safety and Health etc) and external partners such as an A&E Consultant, a Senior Clinical Advisor from the London Ambulance Service, a Coroner and NOMS (Prison Service).

The Custody Directorate works closely with the police custody lead at the MPA to improve safety and standards in custody. This also ensures the involvement of Independent Custody Visitors in improving custody. The Custody Directorate meets regularly with the MPA lead and speaks at ICV Chairs meetings and conferences.

The Custody Directorate has regular contact with the IPCC, HMIC/P and the NPIA to ensure that all relevant information with regards to safety and risk management is disseminated.

John Laing PLC provides non-designated custody staff at three police stations in South East London as part of a PFI contract. The Custody Directorate is working with John Laing PLC to enhance and clarify their management, operational; supervision and training. The directorate has reviewed the training given to Custody Assistants and provided feedback to John Laing PLC and is working with the Procurement Department to change the PFI contract to allow them to receive the MPS training provided to Designated Detention Officers. Designation will equip them with powers under the Police Reform Act and will mean that the MPS can be satisfied that all staff working in custody have been trained appropriately.

National

The Custody Directorate represents the MPS on the National and Regional Custody Forums (and chaired the Regional Forum from November 2009 to May 2011). Both forums include representatives from partner agencies and allows for a wide range of issues to be discussed, including those relating to safety and risk management.

The Custody Directorate actively participated in the 2009 review of the Person Escort Record, used for transferring risk information between agencies. The MPS is representing ACPO in the Prison Escort Contractor Services re-competition and has used this to press the case for the introduction of an electronic PER to enhance the transfer of information between police, escort services, courts, prisons etc and improve the ability to audit completed records.

In 2009 the Custody Directorate worked with the Home Office Police Powers Unit and the Law Society to improve guidance on the safety of solicitors and legal representatives in custody suites.

The Custody Directorate assisted the Independent Advisory Panel (IAP) on Deaths in Custody, part of the Ministerial Council on Deaths in Custody, to discuss improvements to the design of detainee transport.

The directorate regularly attends relevant conferences to ensure that information is obtained and has provided key note speakers on safety in custody.

Improving healthcare

MPS

Forensic Healthcare Services transferred to the Custody Directorate in 2008. The directorate drove through changes to the contract for Forensic Medical Examiners to improve the quality and availability of forensic healthcare. The introduction of Custody Nurse Practitioners (CNPs) and Nurse Managers under Project Herald has further enhanced this service. The use of Patient Group Directions allows CNPs to dispense some controlled medication and the introduction of a Medical Director and a Director of Nursing has also improved our ability to ensure that healthcare standards are reflected in the MPS.

Improvements to Healthcare Professionals rooms have been made in recent years including the provision of lockable medical cabinets, secure disposal of medicines and hand gel dispensers.

Defibrillators have been located within each custody suite since 2007.

The MPS worked with the London Ambulance Service in 2008 to reach agreement with regards to the transportation of persons to hospital rather than to police stations. As this includes those persons who do not have the mental capacity to make decisions this ensures that persons who are intoxicated are taken to hospital rather than to police stations.

National

The Custody Directorate has been represented in discussions to transfer responsibility for the commissioning of forensic healthcare from police services to the NHS.

Improving the built environment

MPS

The Custody Directorate has made substantial improvements to the physical design of custody suites and the equipment provided to ensure the safety of detainees and other custody users. This includes improvements to reduce the risk of ligature points by the alterations to cell wickets, the installation of safer toilet bowls and improved fire/smoke alarms systems.

The Custody Directorate is leading on changes to the custody estate to provide safe accommodation throughout London through the Custody Centre Build programme. New custody centres have been recently opened at Leyton, Heathrow and Barking and Dagenham, with works underway at Croydon and Wandsworth and five further schemes proposed for MPA consideration at the time of writing. The custody suite at Paddington was refurbished in 2009 taking account of the needs of long-term detention, including the effects of this on detainees’ safety and well being. Southwark Police Station has also been refurbished and improved for such use and will shortly become operational.

A build programme is included in Project Herald to assist in the introduction of DDO Inputters throughout the MPS. This programme improves the physical environment of custody suites which allows Custody Officers to better supervise the custody suites.

All custody suites are equipped with CCTV as an aid to safety. The introduction of cell CCTV in at least half of the cells in all custody suites has enhanced the level of supervision which is possible in custody. All cells are equipped with CCTV at newer suites using a digital system. The change to a digital solution at all custody suites is being progressed.

National

The Custody Directorate has worked with the Home Office to improve the design guide for custody suites. The directorate is also represented on the national TACT Detention Programme Board and has regular contact with the other police services building custody suites suitable for long term detention.

Improving the level of staff training

MPS

The Custody Directorate assumed responsibility for the content of all custody related training in 2005 including the Custody Officers and DDO initial and Inputter courses.

The introduction of version control and strict attendance records has ensured that the MPS can demonstrate that all custody staff are trained appropriately. This includes the introduction of refresher training for custody staff and the adoption of the Safer Detention Learning Programme for Custody Officers. In the absence of national guidance for gaoler training the Custody Directorate also introduced a mandatory NCALT package for all staff performing that role.

The directorate established close liaison with TP Training to ensure that custody training remains relevant and up to date and has ensured that recent changes to the way that training is provided in the MPS takes account of the specialist nature of this training.

National

The Custody Directorate assisted the NPIA in drafting the national Safer Detention Learning Programme for Custody Officers (this consisted of training material from the MPS and GMP custody officer courses).

Learning the lessons

MPS

The Custody Directorate assists the DPS to co-ordinate the MPS response to all deaths in custody including providing evidence and information to the IPCC, attendance at inquests and participation in Gold Groups. The directorate also responds to all Coroners’ Rule 43 recommendations. As an example, the inquest for Andrew Schofield in December 2010 found that there were no organisational or training failures in any of nine areas of concern identified by the Coroner.

The Custody Directorate introduced a process to capture “Successful Interventions” and near misses in custody in 2006 to learn from incidents in custody. This has been expanded to include forensic healthcare and has been recognised as one of the best systems in the country. A regular newsletter, “SINEWS”, is distributed widely, throughout the MPS and to other police services and partner agencies.

The Custody Directorate has disseminated such information to custody staff and managers through custody focus days and other workshops centrally and on boroughs. Learning material is also available in a variety of formats including comprehensive information on our Intranet pages and the publication of guides and DVDs. Recent examples include packages focusing on cell checks, the “4Rs”, deaths in custody and constant supervision.

National

The Custody Directorate works with other police services and partner agencies to ensure that lessons are disseminated. In particular, the directorate has regular contact with the IPCC and assisted them in a study of near misses in custody 2008. The directorate also works with other agencies to ensure that the findings of research impacting on safety in custody are recognised. For instance, we worked with Prison Reform Trust in 2008 to improve the identification of learning difficulties and difficulties at an early stage of custody.

Improving policy

MPS

The Custody Directorate assumed responsibility for custody policy in 2004. Since then improvements to MPS custody policy includes: -

• The introduction of the Custody SOP setting out minimum standards and providing guidance to custody staff. A process to ensure regular review and update to reflect changes in law, national guidance etc. has been introduced.
• The introduction of constant supervision of vulnerable detainees in 2007, exceeding the standards for detainee supervision set out in the national guidance. This guidance was reviewed in June 2011 and is bench marked against the Prison Services and the NHS.
• The introduction of pre-release risk assessments in 2009.
• Enhanced auditing and monitoring of standards in custody suites.
• The formalisation of the custody staff handover process to ensure that full information is exchanged changeovers.
• Posters on each cell/detention room door reminding officers of the correct procedures for checking on the welfare of detainees – “the 4Rs”.
• Posters within custody suites reminding detainees that they are at risk if they have swallowed drugs.
• All custody staff now carry cell keys and ligature cutters.

National

The Custody Directorate regularly liaises with the Home Office Policing Powers Unit and the NPIA to gather knowledge and influence changes to legislation and national guidance.

Improve processes

MPS

The Custody Directorate continually reviews custody processes to enhance safety and risk management in custody including: -

• Working with Professor Don Grubin, an expert in risk assessment from Newcastle University to improve the way that information is obtained from detainees during the initial risk assessment. This work, which began in 2006, is a long term project, the results of which will be shared nationally.
• Working with Lambeth NHS to improve the identification and treatment of detainees with mental health disabilities/difficulties.
• Working with the MPA to introduce the role of Familiar Personal Advocate to enhance communication with detainees.
• Contribution to the Detention Command project, part of TP Development, to improve the central control of custody. This will drive performance and address the gap between strategic intention and tactical delivery identified by the IPCC, HMIC etc.
• The introduction of DDO Inputters under Project Herald. With CNPs, this will professionalise the custody team and support Custody Officers, freeing them to manage the custody suite more effectively.

Ensure compliance with guidance and policy

MPS

The Custody Directorate introduced an inspection and compliance process for MPS custody suites in 2007. This takes account of the HMIC/P thematic inspection of all places of detention nationally by assisting Borough Commanders to prepare in advance of a pre-planned inspection and also for unannounced visits. This process also identifies failures, lessons to be learnt and good practice and includes a process to drive improvements where necessary.

Since November 2010 the Custody Directorate Inspection Team has realigned the inspection and compliance process for MPS Custody suites to include a focus on corporate and organisational vulnerabilities. i.e. duty of care, care plans and the pre-release risk assessment process.

National

The Custody Directorate assisted HMIC/P in the design and methodology of the thematic inspection and maintains regular contact with the inspection team. Other police services throughout England and Wales have been assisted in developing their processes based on the directorate’s compliance regime.

Glossary

ACPO

Association of Chief Police Officers

CNP

Custody Nurse Practitioner

DDA

Disability Discrimination Act

DDO

Designated Detention Officer

DPS

Directorate of Professional Standards

FME

Forensic Medical Examiner

GMP

Greater Manchester Police

HMIC/P

Her Majesties Inspectorate of Constabularies/Prisons

IAP

Independent Advisory Panel

ICV

Independent Custody Visitor

MPS

Metropolitan Police Service

MPA

Metropolitan Police Authority

NPIA

National Police Improvement Agency

NSPIS

National Strategy for Police Information Systems

OCU

Operational Command Unit

OLM

Organisational Learning Manager

PER

Person Escort Record

PFI

Privately Funded Initiative

PNC

Police National Computer

SOP

Standard Operating Procedure

SMT

Senior Management Team

TACT

Terrorism Act 2006

TP

Territorial Policing

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