Monitoring of deaths following police contact

Report: 4
Date: 10 June 2005
By: Commissioner

Summary

This report informs the Committee as to the number of deaths following police contact in the year April 2004 - March 2005 and the initiatives currently being undertaken to reduce and prevent similar deaths in the future.

A. Recommendations

That members note the report.

B. Supporting information

1. The total number of deaths following police contact within the MPS for the year April 2004 to March 2005 was thirteen. The totals for the preceding two years were fifteen and seventeen respectively.

2. Home Office Circular 13/2002 defines the definition of Deaths following police contact and places each death into one of four categories which are:

• Category 1: Fatal Road Traffic Incidents Involving Police. This definition covers all deaths of members of the public resulting from road incidents involving the police, both where the person who dies is in a vehicle and where they are on foot.
• Category 2: Fatal Shooting Incidents Involving the Police. This definition covers circumstances where police fire the fatal shots.
• Category 3: Deaths in or Following Custody This definition covers the deaths of persons who have been arrested or otherwise detained by the police. It also includes deaths occurring whilst a person is being arrested or taken into detention. The death may have taken place on police, private or medical premises, in a public place or in a police or other vehicle.
• Category 4: Deaths during or following other types of contact with police. This definition covers circumstances where the person dies during or after some form of contact with police, which did not amount to detention, and there is a link between that contact and the death.

3. Appendix 1 gives details of the 13 deaths in the past 12 months. It shows the Home Office Category of death and the deceased’s age, gender, ethnic origin and brief circumstances.

4. It is not possible to give the length of time the investigations took for the deaths occurring in the last year as many remain on-going, however, taking 20 deaths that occurred in the previous two years the average length of time from commencement of investigation to submission of report to the Police Complaints Authority (PCA) was 330 days.

5. The Directorate of Professional Standards (DPS) has recognised the need to learn from deaths in police custody and indeed all complaint investigations. The creation of the Prevention and Reduction Team (PAR team) is a key and nationally unique initiative to reducing risks associated with deaths following police contact. Appendix 2 shows the work undertaken by the PAR team.

6. Territorial Policing (TP) has recently created the Custody Directorate. This Command gives a single Association of Chief Police Officers (ACPO) lead for custody and strives to assist the overall performance of the MPS by professionalising the custody process and thus minimising risk. The Custody Directorate is seen as vital to ensuring that the various custody facilities throughout the MPS have clear guidance as to policy and procedures.

Organisation of custody suites

7. Currently there are some 53 operational designated (s.35 PACE) police station custody suites within the organisation that are operated on a full time basis. A further 22 (as of 25 May 2005) designated stations are operated on an overflow/special operations basis. This provides the MPS with a combined total of immediately usable detention facilities of some 790 cells and 151 detention rooms.

8. The quality of the station facilities ranges from Victorian buildings to the most modern facilities such as at Wembley and the Private Finance Initiative (PFI) sites such as Lewisham and Sutton. The number of cells varies considerably from as few as four (Twickenham/Walthamstow) to a maximum of 52 (Charing Cross). The last calculation of cell space available was carried out in April (not including safer cells programmes coming back on line) revealed there were 894 cells available to the MPS.

9. The Service Improvement Review of Custody Capacity (SIRCC) made a number of recommendations. Recommendation 3 (to establish a Custody Manager role within each BOCU by October 2004). This has now been achieved and a comprehensive role description has been agreed and circulated across the MPS.

10. Custody suites are managed at a local borough level by locally appointed Custody Managers. Custody Managers responsibilities vary considerably across the MPS. Some are responsible for one custody suite and fulfil this role as their primary job description, whilst others are not only responsible for a number of custody suites but are also expected to fulfil other Borough functions.

11. Boroughs staff their custody suites in a variety of ways using a combination of either full time permanent dedicated custody officers, a mixture of permanent custody officers and sergeants drawn from core response teams or ad hoc staffing from within the core response teams. The Custody Directorate’s ultimate vision is to further professionalise the role of custody officers by promoting the use of permanent dedicated custody staff. To support this and to attract dedicated and competent staff to what is perceived as an unattractive and difficult role the Directorate has submitted a business case to Assistant Commissioner (AC) Godwin for Special Priority Payments (SPP) to be considered for all custody sergeants. Despite the support of AC Godwin, this application was not supported in the recent MPS wide review of SPP’s.

Investigation/monitoring systems

12. Within the MPS when a death occurs the Duty Officer (the 24 hour response inspector) takes immediate control of the situation, he/she will make contact with the DPS Specialist Investigation team (SI) who will attend and take charge of the scene and investigation. The Detective Chief Inspector from SI is responsible for contacting the on call Independent Police Complaints Commission (IPCC) member who will attend the scene.

13. All deaths following police contact are referred to the Independent Police Complaints Commission (IPCC). There are three types of investigation overseen or run by the IPCC they are:

• Police Investigations supervised by the IPCC
• Police Investigations managed by the IPCC
• Investigations carried out by the IPCC’s independent investigative teams.

It is the IPCC who decide the level of supervision basing their decision on the merits of individual cases.

14. Supervised cases: are undertaken by the police (SI) under the supervision of the IPCC Commissioner. They are led by an investigating officer from the police who is approved by the IPCC. In some cases the IPCC may appoint an investigating officer from another force. Throughout the investigation the IPCC commissioner will review its progress and give advice to the investigating officer but the direction and control of the investigation remains with the police investigator.

15. Managed Cases: these are investigations carried out by the police but the IPCC are in overall charge and have direction and control of the investigation. An IPCC commissioner will agree the remit of the investigation and will oversee that it is carried out. The investigation is led by a police officer, which must be approved by the IPCC and in certain cases the IPCC may appoint an officer from another force.

16. Investigations carried out by IPCC investigators: The investigation is conducted by IPCC investigators and overseen by an IPCC commissioner. The MPS has no input into these investigations other than the initial call out.

Police-health interface including mental health and substance abuse

17. The MPS has a number of established groups to develop and co-ordinate initiatives in relation to mental health. These include a Pan-London Mental Health Partnership, MPS Mental Health Group and Mental Health Liaison Officers on every borough.

18. Deputy Assistant Commissioner Paddick has been appointed as MPS lead on mental health issues and has put in place a programme of work to develop practice.

19. Incorporated within the operational response to a mentally disordered person who is violent, is a requirement for them to be removed to an Accident and Emergency unit for medical evaluation, effectively treating such cases as medical emergencies.

20. In respect of the place of safety provisions of Section 136 Mental Health Act, borough Mental Health Liaison Officers are currently negotiating and adopting new mental health protocols with NHS Trusts. There are at present considerable variations within existing protocols around the time required for police officers to remain with the detainee at hospital. The MPS is currently seeking changes to achieve the best handover between police and NHS, to cater for the needs of the patient.

21. At present where a person is detained in a public place as being mentally disordered and in need of immediate care or control, and the person is not displaying any signs that they require emergency medical care, the detaining police officer generally takes that person to the place of safety (a specialist psychiatric reception unit or an Accident and Emergency) in a police van. However, the MPS and the London Ambulance Service (LAS) are advanced in negotiations towards an agreement that will provide an ambulance to convey the person, together with detaining officer, to the place of safety.

22. In respect of substance misuse, all prisoners are referred to a drug referral counsellor should they consent to this. As part of the risk assessment process, the custody officer will include any factors which may indicate whether they are a drug user or under the influence of drugs.

23. The Drugs Intervention Programme has introduced Enhanced Arrest Referral Schemes across the MPS with drug workers having responsibility for assessment referral and case management of detainees who are substance mis-users. This maximises opportunities to engage and retain drug-misusing offenders until specialist drug treatment is available. The programme also allows compulsory drug testing upon charge for certain offences and bail restrictions where tests are positive, to encourage offenders to enter treatment.

Duty of care

24. A duty of care is taken to mean ”reasonable care of people in police custody”. This will include the collection of information relating to the detained person(s), which can be assimilated, from a variety of sources. This would include information available from the detainee, arresting officer, family members, Police National Computer (PNC), observations and experience of the Custody Staff. Additionally, medical opinions can also influence detention and care decisions.

25. The PACE Codes of Practice 3.6 to 3.10 also lays down guidance around the expected level of care to be afforded to detained persons and gives guidance around a structured process for risk assessments. The Custody Officer is responsible for implementing the response to any specific risk assessment, e.g. reducing opportunities for self harm, calling a health professional and increasing levels of monitoring or observation.

26. Current policy dictates that all individuals are assessed to establish what risks are immediately apparent or those likely to be a factor if detention is authorised. This is managed and compiled by the completion of a specific risk assessment form (Form 57M). This forms the basis of information on which the Custody Officer will arrive at their risk assessment. It should be noted that the factors at paragraph 25 might also contribute to the overall risk assessment. This subject is taught on the Custody Officers course at Peel Centre, Hendon.

27. Commander Simon Foy is currently reviewing the content of form 57M. This piece of work is intended to improve the assessment process and its content, with the ultimate aim of making the information gleaned from the detained person more relevant and focussed to the individual’s needs.

28. The organisation recognises that there are occasions where non-fatal incidents occur in the custody environment that are either not reported, or are insufficiently reported and acted upon to prevent further occurrences. The Custody Directorate are engaged with the Directorate of Professional Standards and the MPS Health and Safety branch in developing an improved reporting system to achieve a higher common standard by sharing the organisational learning and promulgating good practice.

Occupational standards/training

29. The generic corporate risk assessment template for all MPS custody suites and detention processes has been reviewed by the Custody Directorate in consultation with the MPS Health and Safety branch in December 2004 and eventually signed off as completed in January 2005. This is due to be published on the relevant intranet site.
30. The Custody Directorate has reviewed all relevant custody policy in line with the Freedom of Information Act. From this they have formulated the Custody Standard Operating Procedures and Guidance (SOP).

31. Before any newly promoted sergeant can be employed in the role of Custody Officer they must have attended the two-week Custody Officers Course and the sergeant’s foundation course. The custody course has been designed to equip all newly promoted officers with the skills and attributes to enable them to manage the custody environment. The Custody Standard Operating Procedure (SOP) maintains that newly promoted sergeants should not be posted into custody suites during the first three months of their probation. The rationale behind this decision is to give these officers time to develop and adjust to their new supervisory roles and responsibilities.

32. All MPS police officers are required to undergo and re-qualify at Emergency Life Support (ELS) standard of First Aid every three years. It has been recognised that there is an increased likelihood of Custody Officers being confronted with medical emergencies in their working environment. Therefore policy has been changed to ensure that those officers performing the roles of Custody Officer and Dedicated Detention Officers (DDO) are trained and re-qualify to this standard every 18 months instead of the three-year period.

33. Since the formation of the Custody Directorate, we have identified a need to update and enhance the skills of all Custody Officers, many of whom have not received any additional training since their initial Custody Officers course. There is anecdotal evidence suggesting that a period of many years have elapsed since some officers have received any meaningful training input. The Custody Directorate are actively championing this cause and are progressing this refresher training at Territorial Policing Headquarters (TP).

34. Although work is still required around funding issues and the Training Needs Analysis (TNA), a commitment is sought for the delivery of a two-day training package on an annual basis. It is envisaged this will be split into two parts, essentially a blended learning package. Day one would be a computer based training package, the second day would revolve around classroom-based lessons with special attention paid to the safer handling of detainees and risk assessments.

35. The National Centre for Police Excellence (CENTREX) is currently researching and developing a new national model for the ‘Safer Detention and Handling of Person’s in police custody’. When completed it is expected to be adopted by the Association of Chief Police Officers (ACPO). This will have a significant impact on all custody related issues. Through MPS involvement with CENTREX in developing this national policy, we are aware that refresher training is going to be strongly recommended and will need to be implemented should the MPS sign up to the policy.

Designing out of suicide/self-harm risks from cells

36. The current standard designs for cells has been developed over several years and fully documented in the Police Buildings Design Guide, which has been produced through partnership working between police estates departments nationally and the Home Office. This incorporates standards for all fixtures and fittings i.e. ventilation grilles, windows, benches, toilet flushes and doors including hatch, that minimise the risk of potential self harm including affixing ligature points.

37. Current changes and improvements are being rolled out across the MPS estate on the ‘safer cells programme.’ Generically this will include replacement of all cell and detention room doors to new specification, replacing existing ventilation grilles, refurbishing/replacing existing cell benches, equipping Custody Suites with CCTV or upgrading to 50% cell coverage and some smoke/fire detection systems. This programme is expected to be completed by the early part of 2006.

The changing nature of detainees

38. It is not possible to exactly categorise the nature of detainees in terms of immigration detainees, those with mental illness, or substance abusers. Whilst the computer generated custody record will record the reasons for detention upon reception at the custody suite, if matters come to light later they will be subject of manual recording on the record and so will not be picked up in statistical examination of custody data. An example of this would be where a person is originally detained for shoplifting which would be recorded on the custody computer. If subsequent enquiries established that the person had committed immigration offences, they would be further detained for those matters with details of that detention being entered in the handwritten part of the custody record.

39. For the financial year 2004/5, 290,245 custody records were opened in the MPS. Of these 42,047 (14%) were for females, 72,444 (25%) were of Black or Black-British self-defined ethnicity and 25,674 (9%) of Asian or Asian-British self-defined ethnicity.
40. Whilst there are no exact statistics in respect of substance abusers in custody, a significant amount of detainees do display signs of alcohol or other substance abuse, as indicated by the increased frequency of Forensic Medical Examiners being required to attend custody suites to examine detainees with symptoms of such abuse.

Abbreviations and acronyms used in this report

• CENTREX - The National Centre for Police Excellence
• DPS - Directorate of Professional Services
• IPCC- Independent Police Complaints Commission
• MPS - Metropolitan Police Service
• PCA – Police Complaints Authority
• PAR – Prevention and Reduction
• PACE - Police and Criminal Evidence Act 1984
• PFI - Private Finance Initiative
• PNC - Police National Computer
• SI – Specialist Investigations
• SIRCC -The Service Improvement Review of Custody Capacity
• SPP - Special Priority Payments
• SOP - Standard Operating Procedures
• TNA - Training Needs Analysis
• TPHQ - Territorial Policing Headquarters

C. Race and equality impact

1. This report presents issues concerning developments in respect of custody provision and death prevention initiatives that have equality and diversity implications. The introduction of the Emerald Custody Directorate, co-ordination of custody provision and enhancement of the supervisory role in custody, is intended to ensure that all detainees are dealt with according to their needs.

2. Every death following police contact is a tragedy for all involved, especially the family and friends of the deceased. All such deaths have the potential to seriously affect community confidence in the police and there have been clear instances where that confidence has been seriously negatively affected.

3. The investigations of deaths following police contact are conducted either independently by the IPCC, or under their direct management or supervision. This is intended to ensure that all such investigations are open and transparent. Independent advisors from communities are often utilised, to provide advice to the investigation and maximise opportunities for community re-assurance.

4. Of the 13 deaths following police contact, three of the deceased were black males and two white females. The very small number of deaths relative to the large amount of contacts with police provides statistics upon which it is very difficult to draw clear conclusions around disproportionality. It is recognised that disproportionality is an issue of great concern to communities and will remain a key area of focus.

5. The Directorate of Professional Standards has recently appointed a Diversity Co-ordinator to provide advice and guidance to investigators to ensure that investigations take into account the needs and concerns of communities.

D. Financial implications

There are no direct financial implications arising from this report.

E. Background papers

None

F. Contact details

Report author: AC Brown, MPS.

For more information contact:

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

Appendix 1

Deaths following Police Contact April 2004 to March 2005

Appendix 2

Initiatives:

1. Custody Command was created in the autumn of 2004

2. DPS Prevention Team

A team formed in April 2004 headed by a Detective Chief Inspector, one Detective Inspector, two Detective Sergeants and two police staff. The team look for learning from discipline and death following police contact matters and make sure that recommendations are recorded, allocated for action and finalised. Work completed or current includes:

• Operation Grant, a database that records all deaths following police contact to provide an audit trail for recommendations and is searchable to allow patterns and trends to be identified.
• Reviewing Specialist Investigation/Coroner recommendations as soon as practicable and to follow up their implementation/progress. Fast time intervention when required.
• Work closely with Emerald Custody Directorate.
• Seeking new ways of making the custody environment safer, by procedural change and training.
• Working in partnership with Health and Safety to encourage officers to report near miss/successful intervention incidents.
• Attendance at the London Custody Forum.
• Defibrillators Project. Three sites have defibrillators available 24/7 on a trial basis.
• Drug Swallowing campaign stickers, introducing Drug Swallowing stickers into all MPS vans, now being extended to Custody Suites.
• Probationer and DDO training. Focusing on vulnerable detainees, awareness of risks together with misconduct procedure the role of the IPCC.
• Liaison with IPCC to fast track learning opportunities.
• Liaison with other forces sharing best practice and learning opportunities.
• Custody officer training. Devised a joint learning package with Emerald Custody Directorate to be delivered by both commands.
• Projects, include safer suits, safer cutlery.
• Custody and Prevention seminars. Four highly successful seminars in 2004, three more delivered April and May 2005, with a satisfaction rating amongst attendees of 96%.

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