Review
Health needs of detainees in police custody in England and Wales.
Literature review
Tatyana Rekrut-Lapa*
, Alexander Lapa
Department of Psychiatry, University of Cambridge School of Clinical Medicine, Box 189, Cambridge Biomedical Campus, Cambridge CB2 2QQ, UK
a r t i c l e i n f o
Article history:
Received 24 February 2014
Received in revised form
15 June 2014
Accepted 6 August 2014
Available online 29 August 2014
Keywords:
Police custody
Detainee
Forensic medical examiner
Police surgeon
Forensic physician
Health care profession
a b s t r a c t
The aim of this systematic is to review and analyse the literature concerned with the health needs of
detainees in police custody in England and Wales.
The healthcare of detainees in police custody is regulated by the England and Wales Police and
Criminal Evidence Act 1984. The Faculty of Forensic and Legal Medicine of the Royal College of Physicians
also sets quality standards for the provision of custodial healthcare. The provision of healthcare in
custody presents a number of challenges including the patient group, the setting and the overlap between
the legal and medical concerns that are addressed by the medical team. Currently, care to the
detainees in custody is delivered by a mixture of private organisations, police-led forensic medical
services and the NHS.
A search of the PUBMED, EMBASE and PsycINFO databases undertaken using the search terms: (police
custody) OR (detainees) OR (police detainees) yielded 830 publications. All of the titles were screened to
identify potentially relevant publications concerned with the health needs of detainees in police custodies
in England and Wales. There were no design specific criteria set for inclusion of the studies in this
literature review. 77 articles were initially identified as relevant and obtained in full. After further
analysis 28 publications were included in this literature review.
A total sample of over 12,000 detainees was examined in this literature review. Approximately 20% of
detainees seen by health care teams suffer from psychiatric conditions. On average, 50% of patients claim
that they have problems with drugs and alcohol. Physical health conditions are also highly prevalent
with up to 74% of detainees requiring regular medication. Forensic medical issues included the management
of detainees who were restrained using handcuffs, irritant sprays and TASER. Detainees who are
suspected of internal drug concealment also require intensive medical input. Injury documentation in
custody is often requested for both the police officer and detainees.
Current literature indicates that mental health problems including substance misuse and physical
conditions are highly prevalent among the custody population and require both emergency and routine
care. The current quality of the health-care services has been discussed and the need for improvement
has been indicated by a number of agencies. Recent attempts have been made to incorporate the
custodial services into the general structure of the NHS, aiming for more robust governance and standardization
of services. Implementation of a routine health promotion service in custody has also been
discussed which can be integrated into the general health care provision during detention.
© 2014 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
1. Introduction
Detainees held in police custody within England and Wales have
a substantial number of rights including the right for healthcare.
The Police & Criminal Evidence Act 1984 provides a legislative
framework for the powers of police officers to combat crime in both
England and Wales. Code C of the act is specifically concerned with
healthcare provision in the custodial setting; it requires the police
officer to seek medical advice if the detainee appears to be suffering
from a physical condition, is injured or has mental illness.1
The
European Committee for the Prevention of Torture and Inhuman or
Degrading Treatment or Punishment (CPT) also attaches particular
importance to the right of a detainee to access to medical care. This,
in the CPT's opinion, is one of the most fundamental safeguards
* Corresponding author.
E-mail address: trl@doctors.org.uk (T. Rekrut-Lapa).
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine
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http://dx.doi.org/10.1016/j.jflm.2014.08.004
1752-928X/© 2014 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Journal of Forensic and Legal Medicine 27 (2014) 69e75
against the maltreatment of detainees and prevention of deprivation
of liberty.2
There is no universal model of healthcare provision for detainees
whilst in custody in England and Wales, as it is commissioned
regionally from a number of privately owned organisations
as well as well as provided by NHS or police led services. The health
care service also varies between doctor led services, doctor/nurse
services, doctor/nurse/paramedic services, doctor/emergency care
practitioner services (who may be nurses or paramedics) and
doctor/paramedic services.3
However, most commonly the custodial
healthcare team includes a Forensic Physician (FP), also known
as Police Surgeon, Divisional Surgeon or Forensic Medical Examiner
(FME) and “Healthcare Professional (HCP)”.3
The HCP is a clinically
qualified healthcare practitioner who has often undergone paramedic
or nurse training and is working within the scope of practice
determined by their professional body.3
Healthcare needs in custody are usually within the expertise of a
primary care setting. These include management of chronic medical
conditions, initial management and referral for emergencies,
drug and alcohol misuse, mental health disorders and injury
management.3
There are also some additional health needs that
may be related to the reason for police detention for example drug
concealment within the body or “body-stuffing”, or as a result of
the policing procedures such as the use of TASER, handcuffs or use
of irritant sprays (IS). Management of these forensic health concerns
may require additional expertise specific to the custody
setting and the population group seen in police custody. The
forensic needs and health care needs can often overlap, hence a
member of the health care team is required to advise the police on
detainee's fitness for detention, interview, charge, transfer and
release.
In recent years there has been an increased emphasis on the
health needs of detainees in police custody aiming to enhance its'
quality and improve access to healthcare for the custodial popu-
lation.4
Therefore, this literature review aims to review and analyse
the literature concerned with the health needs of detainees in
police custody in England and Wales. The findings will also be
compared to the data from international publications with the view
to provide the most up to date information for practitioners who
are working in custody and other healthcare services who, might be
working with this vulnerable group of people both in hospital and
in the community.
2. Methods
A search of the PUBMED, EMBASE and PsycINFO databases undertaken
using the search terms: (police custody) OR (detainees) OR
(police detainees) yielded 830 publications. All of the titles were
screened to identify potentially relevant publications concerned
with health needs of detainees in police custodies in England and
Wales. There were no design specific criteria set for inclusion of the
studies in this literature review aiming to gather all available data.
77 articles were initially identified as relevant and obtained in full.
To assess the possibility of multiple publications of similar studies
from the same cohort, studies were judged to be from the same
cohort if they had overlapping recruitment sites, similar patient
characteristics and similar study data. Where multiple publications
were identified, the data was taken from the first publication
selected by the literature search. Following further analysis of the
full text articles 10 articles were excluded as the studies were based
outside England and Wales, 16 and 18 were concerned with service
provision issues and non custody population respectively, 5 articles
were multiple publications. 28 publications were included in this
literature review. The excluded articles, however, were used to
inform the background, interpretation of data and the discussion.
3. Findings
28 relevant publications with a total sample of over 12000 detainees
were included in this literature review. Table 1 provides a
summary of the publications.
On average 26.9% of detainees entering police custody are
assessed by healthcare team.3
Psychiatric conditions including substance mis-use appear to be
a highly prevalent health problem amongst the custody population
requiring both routine and emergency healthcare. A recent report
published by the Independent Police Complaints Commission
aimed to examine ‘near misses’ (a near miss was defined as any
incident which resulted in, or could have resulted in, serious illness
or self-harm of a detainee) in police custody over a one year period
has reported that 46% of “near misses” were around attempted
suicides and self-harming behaviour while only 14% were due to
medical emergencies.4
A high rate of mental health and substance
misuse problems was also highlighted by all of the publications
included in this literature review.
Physical health conditions commonly seen in police custody
seem to be more prevalent then in the general population of the
same age. Chronic health conditions were more often the reason for
consultation when compared to the general practice setting.3
The
key study highlighting the scale of health problems is designed by
Payne-James (2010).3
It aimed to examine general health issues and
how well they are managed. It included a sample of 168 detainees
assessed by FMEs in police custodies in London. 56% of detainees
had active physical problems and 75% were on prescribed medications.
Physical conditions included diabetes, asthma, epilepsy
and cardiac problems.3
Findings from Payne-James' study were
further supported by McKinnon (2010)10
and Carter et al.'s (2010)9
research that also highlighted the scope of the problem. However,
Carter et al.'s (2010)9
data mainly outlines conditions that require
hospital transfers that are often more serious and need to be
investigated and treated in hospital. It aimed to audit the timing,
number and case mix of hospital transfers for medical assessments.
It examined 12,015 records and identified 188 hospital transfers
mainly resulting from head injury, overdose, and loss of consciousness,
chest pain and acute breathing problems.9
Bussutil
et al.'s (1990)30
survey which assessed regular medication use by
detainees that were in custody in Edinburgh, further supported
evidence of a higher rate of health problems amongst the custodial
population when compared with the general population of the
same age.
Health needs that arise from forensic issues such as the nature of
arrests and the nature of the crime are also prevalent amongst the
custody population. For example, use of IS can cause skin and eye
irritation for up to 6 h following deployment and may require
medical attention.6
Application of handcuffs may also cause
neurological symptoms.21
Detainees that are suspected of internal
drug concealment or “Body-stuffing” presents a number of significant
health concerns and puts a detainee at a high risk of death.9,17
Management of “body-stuffers” in a custody setting require
continue medical input.9,17
4. Discussion
Current literature concerned with the health needs of detainees
in police custody supports the fact that health problems
are very common amongst the police custody population. Mental
health conditions seem to account for the majority of the workload.
Approximately 20% of FME assessed patients have had
mental health concerns or have suffered from depression,10,11
while a third of medications possessed by detainees at arrest
are primarily indicated for management of psychiatric
T. Rekrut-Lapa, A. Lapa / Journal of Forensic and Legal Medicine 27 (2014) 69e7570
Table 1
Summary of publications included in “Health needs of detainees in police custody in England and Wales” literature review.
Name Aim Methodology Conclusion
Young et al. 20135
To investigate: (a) prevalence of LD and/
or ADHD and their relationship with
conduct disorder (CD), (b) impact of
these condition on staff resources, (c)
effectiveness of custody assessment in
identifying the conditions, and (d) the
use of 'Appropriate Adults'
200 custody detainees were interviewed
and screened for ID, ADHD (current
symptoms) and CD.
The screening rates for ID, ADHD and
CD were 6.7%, 23.5% and 76.3%,
respectively. ADHD increased staff
resource after controlling for CD and
time in custody. Reading and writing
difficulties, mental health problems
were identified using custody risk
assessment tools, but the tool is not
effective to assess the need for an
Appropriate Adult. The conditions
increased the demand on staff
resources.
Payne-James et al. (2013)6
To document the effects of SC and PAVA
irritant sprays (IS), by symptom
assessment and medical examination,
within a few hours of deployment.
99 performers were completed to identify
the nature of the arrest, the nature of
exposure to the IS, the type of the IS, the
symptoms experienced and the medical
findings
2.8 ± 2.33 h (mean ± SD) e mean time
of assessment post exposure.
Most frequent sites of application were
face and scalp (n ¼ 78) and the eyes
(n ¼ 32). Most common symptoms:
painful eyes (n ¼ 68); red eyes (n ¼ 58);
runny nose (n ¼ 59); lacrimation
(n ¼ 55); nasal discomfort (n ¼ 52); skin
irritation (n ¼ 49); and skin burning
(n ¼ 45).
Most common medical findings were:
conjunctival erythema (n ¼ 34); skin
erythema (n ¼ 21); and rhinorrhoea
(n ¼ 20).
McKinnon et al. (2013)7
To assess the efficacy of custody
healthcare screening for mental
disorders.
248 detainees were included into the study
and examined for presents of psychiatric
illnesses
96 (39%) of detainees presented with
mental health disorders during the
interview
The police screening procedure only
identified 50 detainees at risk of
psychiatric vulnerability.
Independent police complaint
commission (IPCC) (2012)4
Examined ‘near misses’ in police
custody. A “near miss” (an incident
which resulted in, or could have
resulted in, serious illness or self-harm
of a detainee)
Data collection was via reporting of
incidences by FMEs over one year period in
London, with further interviews to explore
the circumstances of the incidents. 124
incidents were reported.
The most common incidents:
attempted suicide/self-harm (46%);
drugs consumption or possession
(33%); medical conditions (14%) and
alcohol consumption (7%).
Recommendation to improve the
training of custody staff
Rapley et al. (2011)8
To compare police lead screening vs
HCP lead screening in identifying
detainees requirement for health care
input.
In 72 cases “booking in” police risk
assessment tool was compared to a HCP
enhanced mental state examination for
recognizing mental health conditions in
custody.
68% of detainees exhibited a range of
mental illnesses;
Police referred 35% detainees to FME for
mental health concerns and in 14% for
appropriate adult vs 42% and 30%
respectively referred by HCP.
Carter at al. (2010)9
To examine timing, numbers and case
mix of hospital medical referrals and to
review custody procedures for
emergencies management.
12,015 detainee records were examined
retrospectively identifying 188 hospital
transfers.
Cases of head injuries, overdose and
poisoning, unconscious patients,
collapsing patients, chest pain and
breathing problems were the most
common causes requiring hospital
transfer.
McKinnon et al. (2010)10
To examine the health problems and
“mental vulnerability” of detainees and
the efficiency of current health
screening procedures.
The data collection included examining the
records of 307 detainees from 5 custodies in
London who were referred to FME for
assessment.
Injury, epilepsy and asthma are the
most common physical conditions;
depression and self-harm are the most
comment psychiatric complaints. Drug
and alcohol misuse are also highly
prevalent.
Current custodial screening is not fully
effective.
Payne-James et al. (2010)11
Examination of the general health
issues in police custody and how well
this is managed.
168 detainees assessed by FMEs in London
custodies. A sructured questionnaires
recording demographic characteristics,
substance misuse, General Practitioner (GP)
registration and reason for FME assessment
was applied.
56% of detainees had active medical
conditions and 75% of those were on
prescribed medications.
The most prevalent conditions included
mental health, asthma and depression
problems.
Appropriate medical care in custody is
required to reduce the risk to detainees
and others coming in contact with
them.
Scott et al. (2009)12
To examine outcomes and psychiatric
assessment of a population of female
detainees referred to Criminal Justice
Liaison and Diversion Services (CJLD).
217 female records were examined.
Participants were police referrals following
a routine questionnaire assessment for any
health problem requiring FME attention.
91% of female detainees assessed by
CJLD were suffering from mental health
problems;
Custody services for female detainees
(continued on next page)
T. Rekrut-Lapa, A. Lapa / Journal of Forensic and Legal Medicine 27 (2014) 69e75 71
Table 1 (continued )
Name Aim Methodology Conclusion
were sufficient but improvement in
gender-specific alcohol misusers
services is advised.
Olubokun J (2008)13
To highlight problems of vulnerable
adults, especially those with a mental
disorder as defined in section 1 (2) of
the Mental Health Act 1983.
Case study These service users already experience
some form of discrimination within the
wider society and have access to
community services. The role of the
appropriate adult is fundamental.
Norfolk (2007)14
To discuss a case and to review the
literature on managing body-stuffers in
police custody.
Case study of a 50-year old female bodystuffer
who died more than 10 h after
swallowing a plastic wrap of cocaine and
If cocaine is securely wrapped the
asymptomatic detainee is fit to be
detained for 6 h after ingestion;
If cocaine is not securely wrapped or the
packaging is not known 24 h post
ingestion hospital observation is
required.
Scott et al. (2006)12
Describes the mental health needs of
detainees with LD
9014 detainee records were examined by
MH nurses with a further completion of a
mental health assessment of positive cases.
Most of the health needs of LD patients
are not met in custody; Many have
problems that contribute to criminal
behaviour;
Significant change in forensic services is
required to prevent re-offending
behaviour.
Best et al. (2006)15
To assess the Near Miss Incident (NMI)
in custody with the intention of
enhancing detainee care and to assess
frequency and pattern of NMIs
134 London FMEs were sent a questionnaire
to collect anonymised data about the
incidents.
38 NMI were reported by 27 FMEs
The main perceived cause of NMIs
included illicit drugs 12/38, alcohol 17/
38, deliberate self-harm11/38, issues
concerning searches, checks or rousing
8/38, failure of inter-agency
communications 5/38, and resource
issues 4/38. In a number of cases more
than one factor was involved.
Havis et al. (2005)9
To examine 16 cases of internal drug
concealment taken from 43 drugrelated
deaths in custody in England
and Wales between 1997 and 2002.
16 case examination. 8/16 cases have concealed drugs orally
at the arrest. 4/16 had symptoms in a
public place; 4/16 collapsed on arrival
to custody; 2/16 were found collapsed
in their cell;
Drug toxicity was the most common
cause of death (10/16).
Payne-James et al.
(2005)16
Examination of the current
characteristics of drug users and
identification of trends of change.
500 of drug miss-users assessed by FME in
custody completed structured
questionnaires London in 2003. The data
was then compared to a previous 1992
survey.
Illicit drug use has significantly
increased since 1992;
More drug users are currently aware of
Hepatitis B prophylaxis and fewer
people share needles and use IV routes.
Kashani et al. (2004)17
To report a case of intravaginal “body
stuffing” that lead to severe
methamphetamine toxicity.
A case of a 20-year old female detainee who
had concealed drugs in her vagina
developed multiple seizures, altered mental
status, tachycardia and hypertension.
This case highlights the potential for
severe methamphetamine poisoning
secondary to intravaginal stuffing. In
female detainees suspected of body
packing or stuffing, a vaginal exam may
be indicated.
Best et al. (2004)18
To examine 43 cases of death in custody
for potential mental health issues in
drug misusers.
Retrospective case examination. 18/43 cases had some mental health
symptoms;
5/18 had history of self-harm.
10/18 cases had indications of anxiety
or depression.
Greenberg et al.
(2002)19
Examination of MHA 1983 Section 136
application in 6 police custody suites
looking at time scales and outcomes in
Devon and Cornwall
178 detainees completed “study
questionnaire”; Additional information was
obtained from the custodial personnel and
the healthcare team.
35% of arrests were due to self-harm,
22% bizarre behaviour and 15% for
intoxicated;
The average length of detention was
less than 8 h;
32% of assessments resulted in hospital
admission;
Use of this section for drunken
behaviour was inappropriate.
Stark et al. (2002)20
To test the validity of self-reported
substance misuse amongst detained
people in police custody.
166/205 detainees had urine test for heroin,
methadone, cocaine, benzodiazepines,
cannabis and amphetamines to compare to
self reported history of substance mis-use.
History of daily drug use was confirmed
in 75% of methadone, 93% heroin, 98%
cocaine, 87% benzodiazepines, 50%
amphetamines and 88% of cannabis
users;
18% of detainees who denied drug use
tested positively for methadone, 25% for
heroin, 42% for cocaine, 47%
benzodiazepines, 6% amphetamines
and 48% cannabis.
Chariot et al. (2001)21
To assess complications associated with
handcuff application.
Retrospective study of detainees that
developed focal neurological complications
of handcuff application.
12 of 190 (6.3%) had distal neurological
symptoms possibly due to handcuff
application. Potential risk factors for
T. Rekrut-Lapa, A. Lapa / Journal of Forensic and Legal Medicine 27 (2014) 69e7572
conditions.30
The data for female detainees is even more striking
as 91% of female detains assessed by Criminal Justice Liaison and
Diversion (CJLD) services were suffering from mental health
problems and were known to the mental health services.12
Investigations of ‘near misses’ in police custody stated that the
majority of the incidents, which resulted in, or could have resulted
in serious illness or harm to detainees have been due to suicide or
self-harm.4,15
In addition, one in three arrests under Section 136 of
Table 1 (continued )
Name Aim Methodology Conclusion
handcuff neuropathy include a long
duration of application, the existence of
somnolence or acute alcohol
intoxication.
Vaughan et al. (2001)22
To examine the working practices of
four bridewells in Hampshire in relation
to mentally disordered offenders
(MDOs) and diversion services.
A consecutive sample of detainees not
identified by the police as having a mental
disorder was screened for of mental health
problems and suitability for diversion.
7% of detainees had mental disorders
and were suitable for MDOs services but
were not detected by the police vs 14%
in the bridewell without a diversion
scheme. Many individuals without a
formal mental disorder were
inappropriately referred.
Pearson et al.
(2000)23
Identification and treatment of opiate
users at 7 London police stations.
Direct observation of detainees' behaviour
during admission into police custody.
Brief psychiatric rating scale was completed
on all detainees.
4% were identified as opiates users of
whom only 47% reported it during
custody admission process;
Opiate users were detained for longer
than non-opiate users;
Most FMEs managed the addiction
appropriately.
Winter et al. (1997)24
To investigate factors contributing to
suspected offending behaviour by
adults with LD at a city police station.
Adult offences were tested for LD using a
four-item questionnaire. Non-offenders
control group was matched for age, sex and
IQ.
Offenders were more likely to have no
contact with their father, have forensic
family history, been homelessness, use
drugs, experience an excess of recent
life events, have behavioural problems
at school, truancy, been in contact with
police services and probation services.
Trigwell (1997)25
To discuss a case of CS spray being used
to restrain a mentally ill person in
police custody.
A case study It highlights important issues regarding
the welfare of mentally ill people who
are in contact with the police.
Robertson et al. (1997)26
To determine what factors were
associated with the entry of mentally ill
people into the Criminal Justice System
(CJS).
A sample of detainees from 7 London
custodies was observed to detect
psychiatric complaints and was followed
through the CJS.
1.4% was found to be acutely
psychiatrically unwell.
The risk factors for entering CJS
included the presence of violence at
time of arrest, the persistence of (petty)
offending and court warrants as a result
of the failure to appear at court.
Lyall et al. (1995)27
To identify the number of people with a
possible LD suspected of having
committed an offence taken into
custody in Cambridge between 18
January 1993 and 18 March 1993.
251 of 992 detainees in custody were
screened by the custody officer using a brief
questionnaire to assess for reading and
writing difficulties and to see if they had
received extra help at school or attended
special needs schools.
11 (4.4%) attended schools for children
with moderate LD;
1 (0.4%) suspect reported attending a
school for severe LD;
26 (10.4%) attended schools for
emotional or behavioural difficulties or
a learning support unit within a
mainstream school.
Payne-James et al. 199428
To define characteristics drug mis-users
in custody.
150 drug mis-users were assessed using an
anonymised structured questionnaire.
77% used heroin; 30% used both heroin
and cocaine regularly; 72% were
injecting drugs; 32% were being
prescribed drugs (e.g. methadone). 4%
were HIV-positive; 25.7% were
hepatitis-B positive. Only 9.7% were
aware that prophylaxis for hepatitis-B
was possible. 74% had served previous
prison sentences and of those 82% had
used class A controlled drugs whilst
serving the sentence.
Payne-James et al. (1994)29
To undertake a prospective study of
custody detainees seen by a FME for
documentation of alleged assault and
associated injuries.
A sample of 150 detainees was recruited
who required documentation of alleged
assault and associated injuries.
86% were male. Mean age was 29.8
years.
35% said to have unprovoked assaults;
26% stated that injuries occurred at
arrest and 21% claimed that police
caused the injuries;
29% were victims of assault; 17% as a
result of domestic incidents; 8% due to
driving incidents; 20% were police
officers injured during arrests; Victims
of assault were significantly more likely
to be female;
The head was the most common site of
injury. 23% required hospital
assessment.
T. Rekrut-Lapa, A. Lapa / Journal of Forensic and Legal Medicine 27 (2014) 69e75 73
the MHA are carried out to prevent suicidal or self-harming
behaviour.19
Studies of people with intellectual difficulties in custodies
indicated that approximately 1%e6.1% of detainees suffered from
LD5,12
and that the majority of their healthcare needs were not
adequately met, consequently contributing to re-offending behav-
iour.12
In addition, 23.5% and 76.3% detainees in custody are estimated
to suffer from ADHD and Conduct Disorder (CD).5
These
conditions were also not adequately recognised and not provided
with sufficient supported from an Appropriate Adult.5
A higher prevalence of both acute and long-term mental health
problems in custody suggest that police services have an important
role to play in supporting mental health services in the community
as the police custody is often used as a place of safety and a base for
initial assessment during acute psychiatric distress.13
However,
currently there is very little data that audits these services collaboration.
The worldwide data on prevalence of mental health
problem in custody is similar to England and Wales. Laing et al.'s
(2009)32
study from Australia also reported high prevalence of
psychiatric problems in police custodies. The study also outlined
different models of collaboration between the psychiatric service
and the police, which included Crisis Intervention Team (CIT)
model based on a specialised police officers team responding to
mental health crisis32
and the USA based “Civilian Officer Ride
Alone” Model. Both of these models rely on cooperation between
the police and the mental health services and safe and efficient
transfer of care.32
Substance and alcohol misuse is also a major health concern in
custody, which is often directly related to the arrest. 20% of the arrests
are carried out for drunken and disorderly behaviour and 8% for
possession of drugs.16
15% of detainees under Mental Health Act
(MHA) Section 136 had drunkenness or intoxication as a primary
concern.19
In 40% of FME cases, assessment is required because a
person has consumed alcohol.32
Payne-James' (2005) survey indicated
that 18% of detainees admitted significant alcohol mis-use and
30% reported drug mis-use16
highlighting a significant increase in
substance mis-use from 11% reported in a similar survey from 1992.28
One of the difficulties associated with management of substance
misusers in custody is that the self reported history of drug use is not
always accurate. For example, 8% of detainees who reported daily
heroin use tested negatively for heroine on a urine test. In comparison
25% of detainees who denied heroin use had a positively urine
test in Stark et al. (2002) study.20
Accurate history is important as
both over-treating and under-treating the addictions may cause
significant medical complications. 10% of custody hospital referrers
were resulting from an overdose and poisoning and 5% from intox-
ication.9
In addition, 33% of “near misses” cases were also due to drug
possession or intoxication and 7% to alcohol intoxication.4
Custody detainees also seem to suffer from a high rate of
medical conditions including asthma, epilepsy, diabetes10,11
and are
often on regular medications. They also have a relatively high rate
of infections including HIV, hepatitis and tuberculosis.10
More acute
conditions such as head injuries and other injuries, deep vein
thrombosis, pulmonary embolism, chest and abdominal pain often
required hospital transfer.9
Report of “near misses” in custody
highlighted that physical complaints accounted for 15% of all cases.4
The data from Amsterdam, Australia and Germany also similar
outlining that overall physical and mental health of detainees is
worse than for the general population of the same age and
gender.33e35
Drink-driving is an offence that leads to arrest and detention.
However, there is no UK based study that examines this group of
detainees. A case-controlled study based in France identified that
drink-drivers requested medical examination more rarely but were
more frequently alcohol abusers than controls.37
Drivers who did
not complete a breath test more frequently reported assaults and
had traumatic injuries than those who provided a sample. This may
suggest that drink drivers require a more comprehensive medical
assessment; especially those who failed to complete the breath test.
Hence, the UK based studies are needed to assess the health needs
of this group of people.
Detainees may also require medical attention as a result of
policing procedures and the nature of their alleged crimes. For
example, after the use of ISs symptoms of eye irritation, nasal and
skin irritation can last for longer than 3 h,6
which may require
health care input. Long duration of handcuff application may cause
handcuff neuropathy and may trigger a medical review.21
TESA is
another devise that can be used during the arrest procure and
usually requires medical follow up to asses for potential side effects
including burns, intense muscle contraction and cardiac compli-
cations.38
Injury documentation in custody is also done by the
healthcare team and may also relate to arrest procedures as 26% of
detainees claim that they sustained their injuries during the arrest
and 21% state that they were assaulted by the police.29
In addition,
detainees that are arrested under the suspicion of “body-stuffing”
or internal drug concealment also require significant medical input
including hospital transfers as they are at high risk of life threatening
drug intoxication or death.9,17
The funding of this literature review also suggested that further
collaboration and information sharing between the custody
healthcare team and the community and hospital based services is
needed to be able to provide a more consistent patient care.39,40
Health promotion and screening during police custody detention
requires further development and could be integrated into routine
healthcare services.32,43,44
However, the efficacy of current police
administered health screening procedures, only picks up a proportion
of medical problems and an even smaller proportion of
mental health problems.7,8,10
Potentially, further research is needed
to evaluate the strategies for health promotion in custody and to
identify the most efficient ways to deliver services and reach out to
a hard to reach population.
In General, a large number of people are taken into police custody
every year, the data for 2007 obtained from 22 custodies
indicated that 1,573,776 people were held in police custody.
Approximately 26.9% or 423,346 detainees that entered police
custody had undergone medical assessment.3
The total cost to the
taxpayer in England and Wales was estimated to range between
GBP 23,876,730 and 63,967,623.3
Therefore, one of the important
debates that were outlined in many articles summarised in this
literature review included healthcare services improvement and
tightening of the forensic medical regulation to create a uniformed
model for healthcare provision across all regions.3,39,40
This is
especially important, as the healthcare services in police custody
are now undergoing major changes. Recent attempts have been
made to incorporate the custodial services into the general structure
of the NHS, aiming for more robust clinical governance and
potentially initiating standardisation of services. The full arrangements
of service implementation are yet to be determined and may
only apply to England and Wales as the NHS is already providing
the forensic medical services in Scotland. It is also likely that the
practical implementation of the changes will only involve the
already commissioned organisations that provide custodial health
services. These organisations may also introduce their specifications
into the new service arrangements.
In conclusion, this literature review summarised current data on
healthcare needs of the detainee in the police custody in England
and Wales outlining that the custody population has a higher rate
of mental health, addiction and physical health problems than the
general population rate of mental health They are often a hard to
reach group and the police detention can be valuable time where
T. Rekrut-Lapa, A. Lapa / Journal of Forensic and Legal Medicine 27 (2014) 69e7574
healthcare can be provided including health promotion and
screening advise. There are also a number of medical problems that
are associated with arrest procedures that may require forensic
medical input including hand cuffs application, irritant spray use,
TASAR use and injury documentation, some of these problems may
require hospital transfers. Therefore, the finding from this literature
review may be useful not only for forensic healthcare providers, but
also for community based and hospital services who are often
involved in looking after the population group seen in custody.
Ethical approval
None declared.
Funding
None.
Conflict of interest
None.
References
1. Gov.UK. Home Office. Guidance Police and Criminal Evidence Act 1984 (PACE)
codes of practice. OGL. https://www.gov.uk/police-and-criminal-evidence-act-
1984-pace-codes-of-practice#pace-codes-of-practice [accessed 05.07.14].
2. European Committee for the Prevention of Torture and Inhuman or Degrading
Treatment or Punishment (CPT). CPT standards: law enforcement agencies.
Council of Europe; 2002. 1-Rev. 2011.
3. Payne-James JJ, Anderson WR, Green PG, Johnston A. Provision of forensic
medical services to police custody suites in England and Wales: current practice.
J Forensic Leg Med 2009 May;16(4):189e95.
4. Ronnie C, Roberts A. Independent evaluation report of improving health, supporting
Justice: a consultation document. Department of Health; 2008. http://
webarchive.nationalarchives.gov.uk/þ/www.dh.gov.uk/en/Consultations/
Responsestoconsultations/DH_087277 [accessed 15.07.2014].
5. Young S, Goodwin EJ, Sedgwick O, Gudjonsson GH. The effectiveness of police
custody assessments in identifying suspects with intellectual disabilities and
attention deficit hyperactivity disorder. BMC Med 2013 Nov 21;11:248.
6. Payne-James JJ, Smith G, Rivers E, O'Rourke S, Stark M, Sutcliffe N. Effects of
incapacitant spray deployed in the restraint and arrest of detainees in the
Metropolitan Police Service area, London, UK: a prospective study. Forensic Sci
Med Pathol 2014 Mar;10(1):62e8.
7. McKinnon IG, Grubin D. Health screening of people in police custodyeevaluation
of current police screening procedures in London, UK. Eur J Public Health
2013 Jun;23(3):399e405.
8. Rapley M, Sandberg S. Mental health. Raising the bar on police custody. Health
Serv J 2011 Oct 6;121(6277):24e6.
9. Havis S, Best D, Carter J. Concealment of drugs by police detainees: lessons
learned from adverse incidents and from 'routine' clinical practice. J Clin
Forensic Med 2005 Oct;12(5):237e41.
10. McKinnon I, Grubin D. Health screening in police custody. J Forensic Leg Med
2010 May;17(4):209e12.
11. Payne-James JJ, Green PG, McLachlan GMC, Moore TCB. Health issues of detainees
in police custody in London, UK. J Forensic Leg Med 2010;17:11e7.
12. Scott D, McGilloway S, Donnelly M. The mental health needs of women
detained in police custody. J Ment Health 2009;18/2:144e51.
13. Olubokun J. The vulnerable adult in police custody: lessons learned from the
case of R v Paul James Aspinall. Med Sci Law 2008 Jul;48(3):199e202.
14. Norfolk GA. The fatal case of a cocaine body-stuffer and a literature review towards
evidence based management. J Forensic Leg Med 2007 Jan;14(1):
49e52.
15. Best D, Havis S, Payne-James JJ, Stark MM. Near miss incidents in police custody
suites in London in 2003: a feasibility study. J Clin Forensic Med 2006 Feb;13(2):
60e4.
16. Payne-James J, Wall J, Bailey C. Patterns of illicit drug use of prisoners in police
custody in London, UK. J Clin Forensic Med 2005;12/4:196e8.
17. Kashani J, Ruha AM. Methamphetamine toxicity secondary to intravaginal body
stuffing. J Toxicol Clin Toxicol 2004;42(7):987e9.
18. Best D, Havis S, Strathdee G, Keaney F, Manning V, Strang J. Drug deaths in
police custody: is dual diagnosis a significant factor? J Clin Forensic Med 2004
Aug;11(4):173e82.
19. Greenberg N, Haines N. The use of section 136 of the mental health act 1983 in
a Family of Rural English Police Forces. Royal Soc Press 2003;43(1):75e9.
20. Stark MM, Norfolk G, Rogers DJ, Payne-James JJ. The validity of self-reported
substance misuse amongst detained persons in police custody. J Clin Forensic
Med 2002 Mar;9(1):25e6.
21. Chariot P, Ragot F, Authier FJ, Questel F, Diamant-Berger O. Focal neurological
complications of handcuff application. J Forensic Sci 2001 Sep;46(5):1124e5.
22. Vaughan PJ, Kelly M, Pullen N. The working practices of the police in relation to
mentally disordered offenders and diversion services. Med Sci Law 2001
Jan;41(1):13e20.
23. Pearson R, Robertson G, Gibb R. The identification and treatment of opiate
users in police custody. Med Sci Law 2000;40/4:305e12.
24. Winter N, Holland AJ, Collins S. Factors predisposing to suspected offending by
adults with self-reported learning disabilities. Psychol Med 1997 May;27(3):
595e607.
25. Trigwell PJ. The use of CS spray in the mentally ill. J Clin Forensic Med 1997
Mar;4(1):37e9.
26. Robertson G, Pearson R, Gibb R. The entry of mentally disordered people to the
criminal justice system. Br J Psychiatry 1996 Aug;169(2):172e80.
27. Lyall I, Holland AJ, Collins S, Styles P. Incidence of persons with a learning
disability detained in police custody. A needs assessment for service development.
Med Sci Law 1995 Jan;35(1):61e71.
28. Patkar AA, McLean PC. Drug misusers in police custody. J R Soc Med 1994
Nov;87(11):720e1.
29. Payne-James JJ, Dean PJ. Assault and injury in clinical forensic medical practice.
Med Sci Law 1994 Jul;34(3):202e6.
30. Busuttil A, Wallace N. Medication in police custody. J R Soc Med 1990;83/9:
566e8.
32. Carter J, Jenkins R. Substance-misuse: the front line at the police station - an
opportunity for intervention. J Clin Forensic Med 1996;3/4:167e72.
33. Ceelen M, Dorn T, Buster M, Stirbu I, Donker G, Das K. Health-care issues and
health-care use among detainees in police custody. J Forensic Leg Med 2012
Aug;19(6):324e31.
34. Sturgiss EA, Parekh V. The work of forensic physicians with police detainees in
the Canberra City Watchhouse. J Forensic Leg Med 2011 Feb;18(2):57e61.
35. Heide S, Stiller D, Lessig R, Lautenschl€ager C, Birkholz M, Früchtnicht W.
Medical examination of fitness for police custody in two large German towns.
Int J Legal Med 2012 Jan;126(1):27e35.
37. Lepresle A, Mahindhoratep TS, Chiadmi F, Schlatter J, Boraud C. Chariot P Police
custody following drink-driving: a prospective study. Drug Alcohol Depend
2012 Nov 1;126(1e2):51e4.
38. Payne-James J, Sheridan B, Smith G. Medical implications of the Taser. BMJ
2010 Feb 22;340:c853.
39. Payne-James J. Clinical risk and detainees in police custody. Clin Risk 2010;16/
2:56e60.
40. Bond P, Kingston P, Nevill A. Operational efficiency of health care in police
custody suites: comparison of nursing and medical provision. J Adv Nurs
2007;60/2:127e34.
43. Deehan A, Stark M, Marshall J, Hanrahan B, Strang J. Drunken detainees in
police custody: is brief intervention by the forensic medical examiner feasible?
Crim Behav Ment Health 1998;8/3:214e21.
44. Brownell LW, Naik PC. Assessment in police custody of individuals under the
influence of alcohol with co-morbid psychiatric disorders. J Clin Forensic Med
2000 Mar;7(1):39e44.
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