Custody medical information
Significant medical events not consistently recorded or made readily accessible to discipline staff in custodial settings.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Scottish FAI
81match
Xi Biao Huang
(i) All medical assessments, and particularly clinical examinations should be carried out with the use of a professional interpreter where the detainee does not speak fluent English. Whilst the nature of the establishment may mean that it would not be possible or practicable to use professional interpretation services for every interaction with a detainee, the use of fellow...
Matched on
terms: custody, medical
IOPC learning recommendation
78match
Man died while in police custody – Nottinghamshire Police, June 2017
The IOPC recommends that Nottinghamshire Police amends its custody assessment process to include a specific question about whether the detainee has any allergies. Where a detainee has indicated they have an allergy this information should be visible to all custody staff so that they can ensure that the detainee is only provided with appropriate items of food or...
Matched on
terms: custody, information
PFD report
77match
Thomas McAuley
The coroner identified issues with the universal availability and access to Detainee Property and Medical Forms (DPMFs) and other medical records for healthcare staff within the prison system. There was no assurance that medical assessments from custody were consistently seen and considered by prison medical staff.
Matched on
terms: custody, medical
IOPC learning recommendation
77match
Recommendation - Essex Police, December 2023
The IOPC recommends that Essex Police should take steps, in partnership with relevant stakeholders, to ensure healthcare services in police custody best meet the needs of detainees. In particular, Essex Police must make sure detainees have access to and receive appropriate clinical attention as soon as reasonably practicable if they appear to be suffering from physical or mental...
Matched on
terms: custody, medical
Scottish FAI
77match
John James McKelvie
Consideration should be given to the provision of supervised accommodation to which persons arrested or detained under the influence of alcohol might be admitted. Consideration should be given to defining circumstances when the police should inform a police surgeon that a vulnerable person is in custody. c. Where it is possible, all relevant information should be recorded in...
Matched on
terms: custody, information
IOPC learning recommendation
74match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that Thames Valley Police reminds police officers that where the arresting officer does not transport the detainee to custody, information they may have about the detainee is also transferred by some other means and passed on to the custody officer. This follows an investigation into the death of a man at a Thames Valley Police...
Matched on
terms: custody, information
PFD report
73match
Nicholas Rowley
The coroner noted a lack of verbal consultation between medical practitioners and custody sergeants regarding detainee concerns and observation levels. There is a need for joint training on observation levels, precise observation specification, and risks of drug and alcohol abuse in custody.
Matched on
terms: custody, medical
PFD report
73match
Stewart Akins
The coroner identified inadequate information sharing regarding an individual's repeatedly stated intentions to end his own life between the custody record, the investigating officer, and the Crown Prosecution Service. This led to a significant under-reporting of suicide/self-harm risk during bail consideration.
Matched on
terms: custody, information
PFD report
73match
Jeroen Ensink
The coroner noted insufficient recording and escalation of mental health concerns for a detainee, which prevented MASH referral and led to a superficial medical examination. Further concerns included inconsistencies in police statements and custody records regarding injuries and use of force.
Matched on
terms: custody, medical
PFD report
73match
Amy Cross
The coroner identified a lack of a system to ensure important healthcare information, including medication details and physical observations, is passed between different healthcare providers in the criminal justice system during transfers. There is also no standard medical records system accessible by all providers for efficient information transfer.
Matched on
terms: information, medical
Scottish FAI
73match
Martin Jamieson
a) that all personnel, both police officers and civilian staff, involved in the initial processing of a person in custody must ensure that all relevant information about the person is communicated to the Custody Officer; b) that Custody Officers must ensure that during initial processing they undertake a risk assessment of the person based on all relevant information...
Matched on
terms: custody, information
Scottish FAI
73match
Raygen Merchant
I would express a hope that such information, provided it is significant and relevant to the care of a prisoner in custody, would be communicated to those who are responsible for the prisoner’s care. Further, it seems to me that if the prison authorities have information which is potentially relevant to the care of a prisoner either because...
Matched on
terms: custody, information
Article 2 learning point
73match
AA — HMP & YOI Holloway - LP 5
We recommend that policy on the sharing of medical information in the prison setting is clarified and a training programme established to ensure staff understand its implications.
Matched on
terms: information, medical
PFD report
69match
Anthony Fraser
There is no robust system to ensure that summary medical information from electronic records is conveyed to A&E departments when inmates are referred, which risks delaying diagnosis for other patients.
Matched on
terms: information, medical
PFD report
69match
Valdas Jasiunas
The coroner raised concerns about the need for a specific alcohol dependency question in custody risk assessments and noted frequent errors in custody records due to system design. There was also a lack of multi-language versions for alcohol withdrawal information leaflets provided to detainees.
Matched on
terms: custody, information
Inquiry recommendation
69match
AS-9 - Medical Fitness for Detention Forms
Appropriate forms should be made available to allow a medical examiner to declare a detainee unfit for detention and questioning. The decision as to whether a detainee has been declared unfit for detention and questioning should be readily apparent and the reasons for that decision should be recorded. Any conclusion to the contrary effect should be expressed in...
Matched on
terms: medical
PPO recommendation
69match
The Director at Parc
The Director at Parc should ensure that staff assess risk based on all relevant information, including that held in medical records;
Matched on
terms: information, medical
PPO recommendation
69match
The Governor and Head of Healthcare (HMP Highpoint)
The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: • healthcare staff complete the medical information section of the escort risk assessment, accurately reflecting how the prisoner’s current health and medical condition affects their...
Matched on
terms: information, medical
PPO recommendation
69match
The Governor
The Governor should ensure that prison staff understand that medical information about a prisoner must be sought and properly considered when deciding whether to use restraints and in cases where a medical objection is disregarded or is not obtained the reason is documented.
Matched on
terms: information, medical
PPO recommendation
69match
The Head of Healthcare
The Head of Healthcare should ensure that CGL staff consider all relevant information from a prisoner’s medical and prison record, either by accessing the medical record themselves, or asking a member of the healthcare team to provide this information to them.
Matched on
terms: information, medical
IOPC learning recommendation
69match
Recommendation - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police takes steps to ensure that an appropriate and consistent level of information is included in custody records/Electronic Detention Logs (EDLs) when completing a pre-release risk assessment. This should include considering: - minimum standards of information required - any necessary training for custody officers and staf - ongoing monitoring and evaluation of...
Matched on
terms: custody, information
Scottish FAI
69match
Lee Russell
In terms of Section 6(1)(e) of the said Act, that the following were further facts relevant to the circumstances of the death namely, in the event of a person who is in custody being seen by a medical practitioner, the reasons for that person being seen by that practitioner and any treatment and medication received by that person...
Matched on
terms: custody, medical
Scottish FAI
69match
Angela Smith
[51] Although I do not find established that system failures contributed to Angela Smith’s death, I consider the evidence which emerged in this long inquiry should be examined by the police service and NHS to ensure at-risk prisoners are flagged up with all relevant information known about the risk. Where a nursing assessment is indicated this should be...
Matched on
terms: custody, information
Scottish FAI
68match
Jason Jackson
9. In terms of section 6(1)(e) of the said Act, that other facts which are relevant to the circumstances of the death of Jason Jackson are that a standardised approach, such as that set down in the SEWS scale or the Glasgow coma scale, be employed to assess the condition of a prisoner who was suspected of taking...
Matched on
terms: information, medical
PFD report
65match
Richard Green
Concerns were raised that previous self-harm incidents recorded on SystmOne were not identified by prison medical staff due to insufficient review of records and usability issues with the system, leading to a lack of awareness of the prisoner's risk.
Matched on
terms: medical
PFD report
65match
Matthew Sargent
The coroner noted insufficient processes for sharing and reviewing historical prisoner information and risks between staff and healthcare departments. Specifically, healthcare staff were not consistently informed of prisoners with an ACCT history or provided with Prisoner Escort Records upon arrival.
Matched on
terms: information
PFD report
65match
Natasha Chin
The coroner identified issues with medication information sharing between clinical and discipline staff, inadequate opiate and alcohol withdrawal protocols, and a lack of formal audits on medication administration. There were also concerns about the adequacy of staff training.
Matched on
terms: information
PFD report
65match
Robert Brown
Information about prisoners was not consistently available across different prison systems and to all relevant staff, leading the coroner to seek an update on the national development of a unified information system and its implementation timeline.
Matched on
terms: information
IOPC learning recommendation
65match
Man injured during restraint and arrest - Thames Valley Police, March 2018
Recommendation to Thames Valley Police Thames Valley Police should review its training to ensure that it is providing officers with clear advice on what constitutes a head injury and when immediate medical advice must be sought and/or when a detainee must be transferred to hospital. This follows a case where a man appeared to sustain an injury to...
Matched on
terms: custody, medical
CJINI report
62match
An inspection of Prisoner Escort and Court Custody arrangements in Northern Ireland
Matched on
terms: custody
CJINI report
62match
Police Custody – A Follow-Up Review of inspection recommendations
Matched on
terms: custody
CJINI report
62match
Prisoner Escort and Court Custody Arrangements in Northern Ireland: A Follow-Up Review of inspection recommendations
Matched on
terms: custody
CJINI report
62match
Police Custody: The detention of persons in police custody in Northern Ireland
Matched on
terms: custody
CJINI report
62match
Police Custody: The detention of persons in police custody in Northern Ireland. A Follow-Up Review of Inspection Recommendations
Matched on
terms: custody
PFD report
61match
Christopher Shapley
The Person Escort Record form lacked a section for prior hospital treatment and had issues with securely attaching warning documents, hindering information transfer to the prison. Furthermore, prison staff did not always review all available risk information, and efforts to find a suitable cellmate were insufficient.
Matched on
terms: information
PFD report
61match
Adam Rice
The coroner noted that clinicians should inform police about self-discharged patients requiring further investigation, and raised issues regarding West Yorkshire Police custody staff's knowledge of relevant acts and codes, as well as staffing levels during high demand.
Matched on
terms: custody
PFD report
61match
Edwin O’Donnell
The coroner identified that the nurse undertaking initial health screening lacked access to pertinent prisoner documentation, including the Prisoner Escort Report and digital medical records. Concerns were also raised about the recording of such documentation and the sufficiency of ACCT training for probation staff.
Matched on
terms: medical
PFD report
61match
Andrew Carr
Birmingham Prison did not review or record vital information about a prisoner's history of psychoactive substance use upon transfer. The report also highlighted that no solution had been found for five years to prevent drugs being passed through the prison's plumbing system.
Matched on
terms: information
PFD report
61match
Andrew Shirley
Healthcare and mental healthcare staff at HMP Hewell did not sufficiently identify or reduce Andrew's suicide/self-harm risk, nor did they adequately share information. Concerns also noted the Duty Governor's insufficient enquiries regarding a health screen document.
Matched on
terms: information
PFD report
61match
Benjamin Harrison
The coroner identified a lack of night-time healthcare provision and guidance for prison staff assessing prisoners under the influence of substances. Also noted were inconsistencies in policy and practice for sharing essential medication information between healthcare and prison staff.
Matched on
terms: information
Scottish FAI
61match
Andrew Hamilton
1. That a number of defibrillator machines are made available in HMP Dumfries for emergency use by prison staff when the prison medical centre is closed. 2. That Scottish Prison Service (SPS) install and maintain a system of individual cell emergency alarms which is effective at all times. 3. That consideration should be given by SPS to enabling...
Matched on
terms: medical
Scottish FAI
60match
Daryl Malcolm Shearer
But the point here is that it could easily have been avoided if Dr Campbell had written, or better still printed or typed, clear instructions in duplicate to the police to the effect that Mr Shearer should be taken to Raigmore Hospital the following morning to have his cheek x-rayed. But I should have thought that a single...
Matched on
terms: information, medical
PPO recommendation
60match
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: • healthcare staff complete the medical information section of the escort risk assessment to say whether the prisoner’s current medical condition affects their mobility...
Matched on
terms: information, medical
IOPC learning recommendation
60match
Recommendations - North Yorkshire Police, August 2024
The IOPC recommends that North Yorkshire Police should create guidance for custody staff to support them in implementing the College of Policing Authorised Professional Practice (APP) and adhering to Code C of the Police and Criminal Evidence Act 1984 (PACE) with regards to the care of detainees with chronic health conditions. The guidance should support custody staff in...
Matched on
terms: custody, medical
IMB annual report
59match
London short term holding facilities (STHF) (2025)
This report details the operations of London's Short-Term Holding Facilities (STHFs) from February 2024 to January 2025. While positive aspects include safe environments, respectful staff interactions, and improved medical support, significant concerns persist. These include extended detention times in unsuitable conditions, particularly for children, lack of privacy, and inadequate access to medication and reliable translation services. The IMB...
Matched on
terms: custody, medical
PFD report
57match
John Stabler
The coroner noted a need to review and redesign the Prisoner Escort Record. Concerns were also raised about the availability of Wing System medical records in reception areas at HMP North Sea Camp and HMP Lincoln.
Matched on
terms: medical
PFD report
57match
Jonathan Palmer
The coroner noted no effective system exists for prisoners' families to input relevant health information and ensure its dissemination to prison teams and proper recording. Concerns were also raised about the ineffective measures to control contraband, such as illicit drugs like Spice, entering the prison.
Matched on
terms: information
PFD report
57match
Jason Basalat
The coroner noted insufficient information sharing from police and magistrates' court to the prison regarding the deceased's behaviour and mental state. There was also a lack of mental health assessment at court and no consideration of appropriate placement for a vulnerable prisoner.
Matched on
terms: information
PFD report
57match
Heather Birchall
Gaps were identified in G4S healthcare professionals' access to individuals' full mental health background when assessing detainees in police custody, particularly outside of Liaison and Diversion Service (LADS) hours. This limited their ability to make informed decisions regarding further healthcare input, such as formal mental health assessments.
Matched on
terms: custody
PFD report
57match
Zak Farmer
The coroner noted gaps in CRG's procedures for obtaining information from a secure unit following a prisoner's discharge, which meant the prisoner did not receive prescribed medication or full discharge details including diagnoses and care plans.
Matched on
terms: information