Provision of forensic healthcare services for police custodial settings in England, Wales and Northern Ireland: Current practice and implications for other services?

Provision of forensic healthcare services may affect patient safety and criminal justice outcomes. We reviewed models of delivery for services in police custody in terms of cost, types of healthcare professionals and their minimum required experience, training and qualification. Relevant information was requested under the Freedom of Information Act from all police services in England, Wales and Northern Ireland. Additional information was sought from the London Ambulance Service and the Metropolitan Police Service. A third of respondent police services refused to provide the requested information and only a small minority answered the questions in their entirety. Many police services cited excessive cost and commercial interests as reasons for not providing the information. A marked variation in models of forensic healthcare provision across police services which responded was identified. London Ambulance Service call-outs to Metropolitan Police Service custody suites for those arrested varied from 0% to 3.8%. There is substantial inconsistency and variability of information on forensic healthcare services in police custody. A standardised national dataset of all aspects of police custodial healthcare (irrespective of by whom such services are provided) should be established. We advise that the Association of Police & Crime Commissioners, College of Policing the National Police Chiefs' Council and NHS England Health and Justice engage on these matters and work with the Faculty of Forensic & Legal Medicine, the United Kingdom Association of Forensic Nurses and Paramedics, and the College of Paramedics to restart the transfer of all police custodial healthcare services to the National Health Service.

Complaints against health care professionals providing police custodial and forensic medical/health care services in England, Wales and Northern Ireland - what do we know?

Awareness of the nature and frequency of complaints against health care professionals working in police custodial health care services could provide opportunities to improve patient safety. To explore this freedom of information requests were sent to police services in England, Wales and Northern Ireland, to professional regulatory bodies and to the Independent Office for Police Conduct. Eighty-seven percent of police services responded but only a minority provided complete responses, with data not being held, or not being held in an easily retrievable format, being provided as reasons. The nature and frequency of complaints were similar to a previous 2017 study, suggesting a failure to learn lessons from the investigation of complaints and implement change in clinical practice. No evidence of an accessible complaints handling and recording procedure was provided across the police services surveyed. Regulatory bodies provided some information on the nature of complaints made against doctors and nurses working in police custodial settings, but that for paramedics was unable to do so. It is recommended that the communication loop between police services, those bodies providing health care and forensic medical services and regulatory bodies needs to be closed. A common reporting system or the application of established complaints handling procedures and reporting structures, which could be achieved by transferring these services to the National Health Service, may enhance patient safety in police custody.

The use of spit guards (also known as spit hoods) by police services in England, Wales and Northern Ireland: to prevent transmission of infection or another form of restraint?

Spit guards, also known as spit hoods or spit masks (and occasionally bite guards) are devices intended to cover the mouth, face and sometimes the head of a restrained person in order to prevent them spitting at, or biting others. There is substantial controversy about their use with views often polarised between civil and human rights campaigners who express concerns about their utility, their safety, and their possible encroachment on human rights, and in contrast by (predominantly) law enforcement campaigners highlighting concerns about the possible risks of transmission of infection and subsequent need for prophylaxis by law enforcement professionals exposed to biological fluids. This study explored the extent to which police services deploy spit guards and the rationale underpinning their use. A mixed qualitative and quantitative approach was used to analyse data obtained from police services under the Freedom of Information Act. This study shows there is paucity of information readily available from police services in respect of quantifying the numbers of police officers who have contracted infectious disease as a result of spitting and/or bites, despite the fact that risk of infection and the need for subsequent prophylaxis is a driver of police services adopting the use of spit guard devices. Consideration must be afforded to the possibility that the use of spit guards represents a form of mechanical restraint rather than a means to prevent transmission of infection, especially given the paucity of information available from police services in respect of officers who have contracted infectious disease as a result of spiting and/or bites.

Complaints against health-care professionals providing police custodial and forensic medical/health-care services and sexual offence examiner services in England, Wales and Northern Ireland.

Complaints management is an integral component of good clinical governance and an essential contributor to patient safety. Little is known about complaints against health-care professionals (HCPs) in police custodial settings and sexual assault referral centres. This study explored the frequency with which complaints are made against such HCPs working in England, Wales and Northern Ireland. It explored the nature of those complaints and the procedures by which they are investigated. Relevant information was requested from all police services in England, Wales and Northern Ireland; professional regulatory bodies; and the Independent Police Complaints Commission under the Freedom of Information Act (FOIA). Eighty-nine per cent of police services responded to the FOIA request. However, only a minority of these provided detailed information. Many police services cited the provision of health-care services by external providers as the reason for not holding information upon complaints. There was no evidence of any upward trend in the numbers of complaints over the study period. Delayed response to a request for attendance, incivility, medication issues and issues regarding the quality of reports and evidence were amongst the most common types of complaints described. A small number of responders provided copies of the disciplinary procedures used to manage complaints against HCPs. Significant heterogeneity exists in respect of complaints handling procedures across custodial and forensic medical/health-care services and sexual offence examiner services. An opportunity to identify learning for improvement is being missed as a result of the absence of standardised complaints handling procedures.

Effects of incapacitant spray deployed in the restraint and arrest of detainees in the Metropolitan Police Service area, London, UK: a prospective study.

PURPOSE: In the United Kingdom (UK) police restraint and control of detainees is undertaken by assorted means. Two types of incapacitant spray (IS) are approved by the UK Home Office for use: CS (o-chlorobenzylidine malononitrile, dissolved in an organic solvent--methyl iso-butyl ketone and pelargonic acid vanillyamide (PAVA). The aim of this study was to document the effects of incapacitant sprays, by symptom assessment and medical examination, within a few hours of deployment. METHODS: A detailed proforma was produced to explore the nature of the arrest, the nature of exposure to the incapacitant spray, the type of incapacitant spray, the symptoms experienced and the medical findings. RESULTS: 99 proformas were completed. 74 % were completed by detainees and 26 % were completed by police officers. 88 % were exposed to CS spray, the remainder to PAVA spray. The mean time of assessment after exposure was 2.8 ± 2.33 h (mean ± SD). The most frequent sites of IS contact were the face and scalp (n = 78), and exposure to the left and right eyes (n = 32). The most common symptoms were: painful eyes (n = 68); red eyes (n = 58); runny nose (n = 59); lacrimation (n = 55); nasal discomfort (n = 52); skin irritation (n = 49); and skin burning (n = 45). The most common medical findings were: conjunctival erythema (n = 34); skin erythema (n = 21); and rhinorrhea (n = 20). CONCLUSIONS: Symptoms and signs of exposure to IS lasted longer than was expected (a mean of 2.8 h). Approximately 30 % of those exposed had ocular effects and 20 % had skin effects. The findings of this study will enable the guidelines on the expected effects and duration of symptoms resulting from exposure to incapacitant sprays to be reviewed and suggestions for their management to be refined.

Provision of clinical forensic medical services in Australia: a qualitative survey 2011/12.

The provision of clinical forensic medicine services is dependent on jurisdiction and relevant legal instruments. A needs analysis was performed to understand the current service provision within NSW and compare and contrast the service with other jurisdictions in Australia. The aim of this study was therefore to identify the roles, functions and clinical forensic medical services currently provided in the different Australian jurisdictions.

Trends in less-lethal use of force techniques by police services within England and Wales: 2007-2011.

The aim of this study was to determine the incidence of, and any changes in, usage patterns of the less-lethal forms of Use of Force (UoF) modalities--incapacitant spray, impact rounds, and Taser(R)--between 2007 and 2011 by English and Welsh police services. Additional information regarding the deployment and discharge of firearms was also sought. Two thousand Freedom of Information Act applications were made to 50 police services in England and Wales and related jurisdictions requesting the provision of: (a) the total number of deployments of incapacitant sprays, Taser(R), impact (baton) rounds, and armed response units (ARU); (b) the numbers and types of any resulting medical complications; and (c) the details of any local policies requiring assessment by a healthcare professional following a deployment. Responses were received from 47 police services, with only 10 of these supplying complete data. The remainder supplied incomplete data or refused to supply any data under s12 of the Freedom of Information Act (time and cost restrictions). From 2007 to 2011, the use of incapacitant sprays, Taser, and firearms have increased (incapacitant sprays deployed: 3496, 3976, 6911, 6679, 6853; Taser deployed: 499, 2659, 4560, 6943, 7203; Taser discharged: 15, 85, 161, 338, 461; firearms: 0, 7, 4, 19, 32). Baton rounds and ARU use showed greater variability over the same time period (baton rounds: 1007, 1327, 1123, 1382, 1278; ARUs: 11688, 13652, 13166, 13959, 12090). Only two services could provide details of medical consequences from use of incapacitant sprays, Taser, and baton rounds. No service could provide details of any related medical complications following use of firearms. Data collection and release are variable and inconsistent throughout English and Welsh police services and thus caution is needed in determining trends of UoF techniques. Deaths or injuries inflicted using UoF techniques result in much public scrutiny and the low level of data recorded in these cases is of concern. Common systems for recording use and adverse outcomes of UoF techniques are needed to inform the public and others who have concerns about such techniques.

Conducted energy devices: pilot analysis of (non-)attributability of death using a modified Naranjo algorithm.

Alleged fatalities associated with conductive-energy devices (CEDs) are similar to alleged serious adverse events (SAEs) after the use of pharmaceutical products: both types of case arise rarely, in complex (if not unique) combinations of circumstances, frequently when there are multiple concomitant putative aetiologies for the injury, and after the suspected product has been previously well-designed and tested. Attribution (or otherwise) of SAEs to pharmaceutical products is often assessed by use of the Naranjo algorithm. The purpose of this study was to investigate whether an adapted Naranjo algorithm could be used to assess alleged CED-associated fatalities. Unique cases had four independent identifiers. Prospectively, 7 (of the 10) Naranjo algorithm questions were chosen as being potentially applicable to CED use. These had maximum score 9, and the associated ordinal probability scale (doubtful, possible, probable, and definite) was retained by linear proportion to the integral scores. An arbitrary requirement was for database sufficiency≥50%=([n unique cases×7 questions answerable]×0.5); a pilot sample (n=29 unique cases) suggested feasibility (see below). One hundred and seventy-five unique cases were found, with a data sufficiency of 56.8%. Modified Naranjo algorithm scores had an unequally bimodal distribution. CED-attributability was suggested in 21 (12% of 175) cases. Substantial numbers of concomitant conditions existed among cases with low algorithm scores, all being potentially lethal under field conditions without CED exposure. The number of CED-administered shocks sustained was unrelated to CED-attributability of fatality. Two of the Naranjo questions (regarding dechallenge and the effects of challenge with a non-identical but similar agent) proved to be non-contributory. An algorithmic approach to assessment of CED-associated fatality seems feasible. By these pharmacovigilance standards, some published case fatality rates attributable to CED exposure seem exaggerated. CED-attributable deaths have close similarity to Type-B SAEs. The latter are rare, unpredictable, and usually due to a patient idiosyncrasy. In the person being restrained, such idiosyncratic factors may be unavoidable by law enforcement officers (LEO) in the field. These are unlike predictable (Type-A) SAEs, which have their corollary amongst secondary CED-associated deaths, e.g., head injury among cyclists or ignition of an inflammable atmosphere by the CED, and are identifiable risk factors for which LEO can train. Regardless, absolute CED tolerability is obviously greater than that for firearms. A prospective registry of CED deployments would measure this more precisely.

Quality of photographic images provided for injury interpretation: room for improvement?

The aim of the study was to determine the quality and nature of photographic images submitted to the National Injuries Database (part of the National Policing Improvement Agency) in the United Kingdom, for expert assessment and interpretation. A prospective analysis of cases (n = 50) were assessed for the number, origin, type and quality of images. Of 1,332 images in 50 cases submitted to the National Injuries Database, only 24% were appropriately labeled with an index; 5% were unfocussed; 64% had no rules or measurement scales; 0% had color charts or bars; 1.3% were of unidentifiable parts of the anatomy. The images sent to the National Injuries Database for interpretation originated from a variety of sources with no consistency in presentation. In particular, features such as rules or scales, color charts and appropriate labels with indexes, were absent in a variable number of cases, although these factors may at times be crucial to interpretation. It would be appropriate for standards to be developed and used for consistency in image capture, presentation and reproduction for interpretation for court settings in order to improve the quality of evidence available.