Recurring concern

Unreliable progression of people through police custody

First to latest report 6 Jan 2014 — 23 Jul 2019

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
2

What this concern includes

Includes failures in police custody arrangements for progressing detained people through reception, waiting areas, interviewing, processing and related transfer stages, including prolonged van-dock waits, absent or inadequate waiting-area risk assessment and triage, insufficient processing coverage, and delays caused by unclear or incomplete custody-progression procedures.

What is not included
  • Excludes ordinary custody delays where no unsafe duration, deficient progression process or associated risk-management failure is identified.
  • Excludes clinical assessment, observation, healthcare, handover and emergency-response failures unless they directly impair progression through police custody.
  • Excludes unlawful detention caused solely by release-date calculation, recall or sentencing administration; those belong to a distinct release or detention-decision concern.
  • Excludes general police staffing shortages unless they directly cause unreliable custody progression or leave detained people waiting beyond a safe timeframe.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Adam Harris · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Adam Harris died at Tameside General Hospital on 20 April 2018 from alcohol and cocaine toxicity after collapsing at Ashton Police Station following his arrest and detention. Concerns included the absence of documented triage or risk assessment while prisoners waited in the van dock, lack of searches before transport, unclear handover arrangements, delayed creation of the custody record, and inconsistent evidence about his position in the cell while confused and suspected to be intoxicated.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Prolonged prisoner waiting periods in the van dock area

    Wider context from the report

    “1. The inquest heard that there was no formal documented triage/risk assessment in place when a prisoner was held in the van dock area pending space becoming available in the custody suite. The inquest heard that whilst the average wait time in the van dock area across GMP was 15 minutes on occasions the waiting period could be in excess of 60 minutes; ”

    Source location

    Adam Harris · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of formal documented triage and risk assessment for prisoners held in the van dock area

    Wider context from the report

    “1. The inquest heard that there was no formal documented triage/risk assessment in place when a prisoner was held in the van dock area pending space becoming available in the custody suite. The inquest heard that whilst the average wait time in the van dock area across GMP was 15 minutes on occasions the waiting period could be in excess of 60 minutes; ”

    Source location

    Adam Harris · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with Greater Manchester Combined Authority to explore introducing formal pre-detention medical assessments for detainees waiting over 30 minutes in a police vehicle.

    Verbatim wording from the response

    “Greater Manchester Police are currently working with Greater Manchester Combined Authority and are exploring the introduction of a formal pre-detention medical assessment carried out by a Health Care Professional where a detainee remains in a Police vehicle in a van dock for a period in excess of 30 minutes.”

    Source location

    2019-0247-Response-from-Greater-Manchester-Police
    Page 2 · response
    Published 9 September 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise and republish the Transportation of Detained Persons procedure, including dynamic risk assessment and detainee-management responsibilities.

    Verbatim wording from the response

    “It is not current procedure to complete a formal documented risk assessment whilst a detained person remains in a police vehicle, in a van dock, awaiting authority to proceed into the custody suite. Procedures that are in place demonstrate risk assessment is an ongoing process from arrest through to custody handover.”

    Source location

    2019-0247-Response-from-Greater-Manchester-Police
    Page 1 · response
    Published 9 September 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing allocation, dynamic risk-assessment and custody-prioritisation procedures are relied upon instead of introducing formal documented risk assessments in the van dock.

    Verbatim wording from the response

    “Response: With regard to the waiting time in the van dock - detainee cell space is allocated presently by a centralised GMP “cell allocation team”. They monitor detainee numbers (in situ or those en route), detainee needs, complexities and staffing levels in order to make an informed decision as to which is the most appropriate custody office to send the arrested person for an allocation. The allocation team make direct contact with the custody office to advise them a detainee is en-route; this in itself is a further check to determine that the custody suite has the capacity and means to accept the detainee. Where there is any need to escalate an allocation decision – there is always a Custody Inspector (Custody Bronze) designated to assist. This approach ensures that the waiting time that a detainee has, is as short as possible taking account of all contributing factors.”

    Source location

    2019-0247-Response-from-Greater-Manchester-Police
    Page 1 · response
    Published 9 September 2019

    Open published response

  2. Manchester South

    AI-generated summary

    Billy Paul Thomas Salton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to staff the Prisoner Processing Unit overnight

    Wider context from the report

    “1. During the course of the evidence I heard that Mr Salton 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 “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy. 2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton 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 observations are set as they are – i.e. what the medical condition/ concern is. 3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record. 4. 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. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost 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. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate. 7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen. 1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy). 2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody. 3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked. 4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded. 1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody. 2. Staff should be reminded that all cell checks should be accurately documented. 3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY. ”

    Source location

    Billy Paul Thomas Salton · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026