Billy Paul Thomas Salton
6 Jan 2014 · Coroner Joanne Kearsley · Manchester (South)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. detention longer than required
“During the course of the evidence | heard that Mr [name redacted] had remained in custody overnight and was not progressed as quickly as he could have | been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP”
2. lack of observation protocol understanding
“There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr [name redacted] was on and why he was on those observations. It is important that everyone who | has care of someone in custody understands what the observations have | been, what they should be, when they are to be carried out, whether rousing is required and why the observaticns are set as they are - i.e. what the medical condition/ concern is.”
3. inaccurate visit recording
“When the deceased is visited and checked all such visits should be | accurately recorded on the custody record”
4. missing risk assessment documentation
“Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.”
5. ineffective handovers
“Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. important information was missed or iost in translation. Proper handovers should take place as to a detained person's condition, risk assessment, any medical condition, level of visits and other important matters.”
6. incorrect escort documentation
“The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“Risk assessments carried out whilst in police custody should be recorded when they are done.”
Later report
“It was therefore decided to hold a joint medical and police exit risk assessment when someone who has displayed self- harm ideation or behaviour leaves custody”
Closely relatedConfidence 0.80 · moderate
This report
“When the deceased is visited and checked all such visits should be | accurately recorded on the custody record”
Later report
“The Custody Sergeant did not open a custody record immediately on [the deceased] } Harris's arrival in the custody office. He used a piece of paper to record the”
Responses
2014-0002-Response-by-Greater-Manchester-Police.pdf ↗· Greater Manchester Police
Stated action
“| have an ongoing review of divisional policing entitled 'Transforming Divisional Policing' which looks at all aspects of improving the operational service we provide. | have specifically asked it to look at finding ways of processing detainees with greater efficiency in order to reduce their periods of detention,”
Stated action
“GMP has reviewed its arrangements for communication between custody and clinical staff to negate the practice of MEDACs staff working on two separate records of notes and to improve the continuity of care provided to detainees with health needs”
Stated action
“We already have a process that checks custody records to ensure visits are timely and carried out in accordance with the sergeant's risk assessment”
Stated action
“Since the death of Mr [name redacted], Custody Branch has significantly upgraded its ICIS computer system. This system prompts Custody Sergeants to undertake further reviews linked to specific/significant events affecting the detainees period of detention, including an exit risk assessment”
Stated action
“We have conducted a review of handovers between sergeants. As a result we have made it clear to sergeants that the handover need not be a comprehensive review of each detainee. Rather, they should have completed the Custody Summary Screen so that all the relevant detail is available on the ICIS system and the handover should contain key risk issues, for example medical conditions, medication required and so forth”
Stated action
“Since your observations we have put out improved guidance on completion of the PER form to sergeants which include what to record, when it is to be done and how it is to be signed off”
2014-0002-Response-by-Medacs.pdf ↗· Greater Manchester Police
Stated action
“The access of Medacs Policies and Procedures to Medacs staff | was also concerned to hear that | was not aware of the Medacs Epilepsy Policy. He said in evidence that he had no specific recollection of the epilepsy policy, but he was aware that the Medacs policies were available in a 'loose leaf binder in most custody suites'. Asa very experienced FME J gave evidence that he had been asked to review most of the policies, but he could not specifically recall this one”