16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to check and update Prisoner Escort Records before release View source
This report raised 27 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” Source location Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Open source report
Concerns raised 9
Failure to record later healthcare assessment needs View source Failure to record changes to detainee observation levels View source Unrecorded informal cessation of detainee rousing checks View source
Failure to implement and record required detainee observation levels View source Failure to refer detainees for medical review and record acute symptoms View source Failure to open custody records and complete risk assessments View source Failure to ensure legible custody-record entries and clarify illegible writing View source False recording of detainee cell checks View source Incorrect recording of healthcare referrals in custody records View source See 6 more concerns
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Neil Budziszewski · 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
Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record later healthcare assessment needs
Wider context from the report “(7) The afternoon custody sergeant recognised guidance that a doctor would normally be asked to attend for an alcoholic detainee, but failed to record on the custody record or risk assessment that Mr Budziszewski should be considered for an assessment later on .
” Source location Neil Budziszewski · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record changes to detainee observation levels
Wider context from the report “(22) No note was made in the custody record of the decision to place the prisoner back on 30 minute checks after the retching episode so that later officers would be aware.
” Source location Neil Budziszewski · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unrecorded informal cessation of detainee rousing checks
Wider context from the report “(8) The afternoon civilian detention officer believed that Mr Budziszewski had been taken off rousing checks by 8pm because he had been in custody some five hours and rousing ‘was no longer necessary’ . This seems to be a commonly made informal decision with no record made .
” Source location Neil Budziszewski · Prevention of Future Deaths report
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 Failure to implement and record required detainee observation levels
Wider context from the report “(6) The afternoon custody sergeant at Ecclesfield failed to place Mr Budziszewski on 30 minute routine checks in breach of PACE Code C (paragraph 9.3). Indeed, there was no annotation on the custody record of the level of checks required
” Source location Neil Budziszewski · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to refer detainees for medical review and record acute symptoms
Wider context from the report “(20) Shortly after 3am if was noted by the night custody sergeant that the sound of retching could be heard from one of the cells. Investigation by the night detention officer showed this to be Mr Budziszewski. This caused his custody record to be reviewed (for the first time) and earlier notation concerning dependence on alcohol and the use of drugs was apparent. No action was taken to refer Mr Budziszewski for medical review even though the doctor was visiting another prisoner in the custody area at the time . No record of this incident was made in the custody record .
” Source location Neil Budziszewski · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to open custody records and complete risk assessments
Wider context from the report “(1) When Mr Budziszewski was first presented to the Ecclesfield afternoon shift custody sergeant he accepted custody without opening a custody record or completing a risk assessment . Whilst it is accepted that Mr Budziszewski was in drink at the time and un-cooperative there appears to have been no thought given to a risk assessment.
” Source location Neil Budziszewski · Prevention of Future Deaths report
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 Failure to ensure legible custody-record entries and clarify illegible writing
Wider context from the report “(13) A significant amount of the handwriting on the custody record (notably including that by the reviewing inspector) was illegible. Yet nobody sought clarification of what had been written .
” Source location Neil Budziszewski · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation False recording of detainee cell checks
Wider context from the report “(24) The night shift civilian detention officer made false entries of having carried out cell checks on the deceased at 0335 and 0430. On the first occasion it was written that Mr Budziszewski was asleep and breathing regularly but in fact this entry (written later) was made on the assumption that a visit must have been made at around that time and that is what would have been found.
” Source location Neil Budziszewski · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Incorrect recording of healthcare referrals in custody records
Wider context from the report “(27) Further, the custody record had been incorrectly marked during the night that Mr Budziszewski had been referred to a doctor which would at least be initially misleading to the morning shift although there was obviously no paperwork from a doctor.
” Source location Neil Budziszewski · Prevention of Future Deaths report
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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 Remind custody staff to record all decisions about detainee checks in custody records.
Verbatim wording from the response “This is contrary to training which has been provided. All staff have now been reminded that all decisions regarding checks of detainees must be recorded on the custody record and that if the decision is not recorded then the decision has not been made. This was dealt with custody Inspectors on 15 April 2015 and other staff will be reminded of this requirement in a briefing document by the end of May 2015.” Source location 2015-0109-Response-by-South-Yorkshire-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement digital custody records requiring electronic recording of checks, observations, assessments and associated audit times.
Verbatim wording from the response “It is accepted that Mr Budziszewski should have been on 30 minute rousing checks and that this should have been annotated on the custody record when the checks were undertaken. South Yorkshire police have now moved to fully digital custody records and each check will have to be placed onto the electronic custody record. This system has been in place since 17 February 2015 and it is mandated that the checks have to be carried out. The appropriate checks are preselected in a drop down menu on the electronic system and therefore clearly defined according to the appropriate guidance.” Source location 2015-0109-Response-by-South-Yorkshire-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate alcohol withdrawal risks and acute withdrawal symptoms into custody guidance and first-aid training.
Verbatim wording from the response “The training programme which has been provided, both the initial training and the annual refresher, make specific reference to the risks of alcohol. South Yorkshire Police Training department have now been asked to incorporate the risks of alcohol withdrawal and acute alcohol withdrawal symptoms into the training and specifically the impact that this has on the risk assessment in custody. The training which is provided is based on the Home Office training programme and therefore a limited number of health issues are included within the training. It would be difficult to incorporate all health conditions into this training as time is limited. This will be part of the general guidance which will go out from Inspectors by 31 May 2015 and will be included in the next round of First Aid training provided to custody staff.” Source location 2015-0109-Response-by-South-Yorkshire-Police
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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 Address healthcare-provider arrangements concerning medical assessment of alcohol-related detainees.
Verbatim wording from the response “Healthcare provision to South Yorkshire Police is provided by a private company. The practice of that company is that they will not routinely see a detainee where that detainee is under the influence of alcohol and they have been in custody for less than six hours. The only exception is where the factors referred to in paragraph five are present:-” Source location 2015-0109-Response-by-South-Yorkshire-Police
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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 Remind custody staff of the obligation to seek medical attention when detainees present possible medical concerns, including when they decline an offer.
Verbatim wording from the response “The custody sergeant would be expected to have requested a medical review for the detainee following this action. PACE Code C is clear and note 9C is clear that if there is any doubt over the condition of a detainee then medical attention should be sought. As discussed at paragraph 17, custody staff will be reminded of this in writing by 31 May 2015 and also in subsequent training. It is also anticipated that the new electronic risk assessment will trigger the requirement for a medical review when it is completed. The electronic custody log will have to be updated regularly and the time the log is updated will be recorded which will provide for greater accountability.” Source location 2015-0109-Response-by-South-Yorkshire-Police
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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 Thirty-minute checks were unnecessary at Bridge Street because the detainee was never placed in a cell and remained under constant supervision.
Verbatim wording from the response “It is also the case that the risk assessment, once the detainee arrived at Bridge Street, did not refer to the requirement for 30 minute checks because he was never taken to a cell at Bridge Street and therefore under constant supervision. It is right that if he had been taken to a cell then the record would have been updated with the appropriate check times required.” Source location 2015-0109-Response-by-South-Yorkshire-Police
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6 Jan 2014 Billy Paul Thomas Salton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4
Failure to document non-assessment and avoid misleading medical records View source Failure to accurately document custody cell checks View source Failure to accurately record custody visits and checks View source
Failure to record custody risk assessments and rationale for unchanged assessments View source See 1 more concern
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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.
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× 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 document non-assessment and avoid misleading medical records
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
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 Failure to accurately document custody cell checks
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
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 Failure to accurately record custody visits and checks
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
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 Failure to record custody risk assessments and rationale for unchanged assessments
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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct annual audits of clinicians’ medical-note quality, address concerns individually and complete the scheduled re-audit.
Verbatim wording from the response “Lead Doctors and Lead Nurses have been tasked with completing annual audits of the quality of the medical notes of all clinicians in their teams, and have been asked to address any concerns on an individual basis with staff. A re-audit is due in June 2014.” Source location 2014-0002-Response-by-Medacs
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use electronic records instead of handwritten forms, removing the requirement to label examinations as completed or refused.
Verbatim wording from the response “I note your recommendation that if a clinician is unable to complete an assessment that this should be explained and ‘any potential misleading information should not be recorded’. Given the nature of the work in police custody, our healthcare staff frequently attend to assess detainees who refuse to co-operate. In most cases it is for the detainee to decide whether they consent to an assessment, or choose to refuse, or answer questions about their health. Our investigation report identified that in this case a nurse circled “completed” on the handwritten form re: “examination/observations completed/refused”. Mr Salton had answered some questions, but refused to answer others. The handwritten forms are no longer used, and the electronic record system does not ask the staff member to select either ‘complete’ or ‘refused’.” Source location 2014-0002-Response-by-Medacs
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide staff inputs using case studies to reinforce recording risk-assessment rationales and custody actions accurately.
Verbatim wording from the response “I do agree with this but can see how this can degrade into quite significant events not being accurately recorded. We will, therefore, shortly be giving a series of inputs to staff which will” Source location 2014-0002-Response-by-Greater-Manchester-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require recording of unchanged risk assessments and monitor compliance through Custody Inspector dip sampling.
Verbatim wording from the response “You are right to point out that all risk assessments, including those where there is no change in the detainee’s circumstances, should also be recorded. This requirement has been communicated to custody staff and is currently being monitored by Custody Inspectors undertaking dip sampling of custody records.” Source location 2014-0002-Response-by-Greater-Manchester-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assessments cannot always be completed because detainees may refuse to cooperate or answer health questions.
Verbatim wording from the response “I note your recommendation that if a clinician is unable to complete an assessment that this should be explained and ‘any potential misleading information should not be recorded’. Given the nature of the work in police custody, our healthcare staff frequently attend to assess detainees who refuse to co-operate. In most cases it is for the detainee to decide whether they consent to an assessment, or choose to refuse, or answer questions about their health. Our investigation report identified that in this case a nurse circled “completed” on the handwritten form re: “examination/observations completed/refused”. Mr Salton had answered some questions, but refused to answer others. The handwritten forms are no longer used, and the electronic record system does not ask the staff member to select either ‘complete’ or ‘refused’.” Source location 2014-0002-Response-by-Medacs
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Includes failures of the police custody-recording process that result in inaccurate, incomplete, omitted or misleading records of force, healthcare referrals, visits, observations, risks or other safety-relevant custody information.
