Recurring concern

Unreliable healthcare referral for medically vulnerable detainees

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First reported 23 Mar 2015•Latest report 4 Mar 2025

Definition

What this concern includes

Includes failures in custody referral processes for detainees to healthcare professionals or forensic medical examiners where relevant medical, injury, intoxication, safeguarding or vulnerability concerns are not reliably considered or acted upon.

Not included

  • Excludes failures in clinical assessment or treatment after an appropriate referral has been made.
  • Excludes generic custody staffing, training or communication deficiencies unless they directly cause an unsafe detainee healthcare-referral decision.
  • Excludes referrals concerning non-detainees or non-healthcare services.
  • Excludes failures limited to substance-use management where the wider detainee healthcare-referral decision is not deficient.
Reports
4

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2015–2025

First to latest report issue date

Stated actions
8

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

College of Policing1
Metropolitan Police Service1
National Police Chiefs’ Council1
Police and Crime Commissioner for West Midlands1
South Yorkshire Police1
West Midlands Police1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Liverpool and the Wirral

    AI-generated summary

    Robert John EVANS · 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

    Robert John EVANS was found dead at his home in Liverpool on 3 July 2022. His death resulted from drug use and underlying pneumonia, with fractures sustained during police detention contributing more than minimally to his death. The principal concerns were the lack of guidance, training, medical escalation and information-sharing when a person detained for a drug search is suspected of swallowing drugs, particularly after release from detention.

    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

    Lack of guidance, training and an urgent medical response pathway for non-arrested detainees suspected of swallowing drugs

    Wider context from the report

    “The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that “...If officers know or suspect that a detainee has swallowed or packed drugs...they must treat the person as being in need of urgent medical attention and transfer them straight to hospital”. However: (a) a person detained for a search under the Misuse of Drugs Act does not come to the attention of a Custody or Detention Officer, unless arrested; (b) there is no guidance (known to the court) to assist officers involved in such a search as to what they should do; (c) there is seemingly no power for officers to convey to hospital somebody detained under these provisions (but not arrested), if that is against their wishes. The upshot seems to be that, whilst the risk arising from swallowing a package containing drugs is the same in each case, there is a material difference between how different types of detainee are managed, depending upon whether an arrest has taken place. Officers told the court that if somebody declines an offer of medical attention they simply monitor their condition, for signs of any change or deterioration. However, even if that is effective and adequate, any monitoring inevitably ends when the individual is released from detention. In this case that was little more than an hour after the suspected swallowing event. When he was returned home, officers gave no advice to the Deceased or his family about the need for continued monitoring. There appears to be no guidance directed towards them as to what advice should be given. One officer said that nothing could be said to the family (about the need to keep him under close watch, because of the risk), because that would breach the individual’s right to privacy. It occurs to me that a person suspected of involvement in a drugs deal (even if nothing is found on a search) might well be keen to avoid further attention from the police and/or medical services as quickly as possible, for fear of something being found that might incriminate them. I am concerned that a person detained for the purposes of a search under the Misuse of Drugs Act, who is then suspected of having swallowed drugs, might be exposed to a risk of death (or other significant harm) if they do not receive the sort of medical attention which the guidance to Custody and Detention Officers considers an ‘urgent’ requirement, and/or if they are not given appropriate guidance on their release from detention. I am further concerned that officers are not given guidance or training in how to address this risk, by means of communication or otherwise. ”

    Source location

    Robert John EVANS · Prevention of Future Deaths report
    Page 2 · 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

    Provide publicly available APP guidance requiring urgent hospital treatment, coordinated risk assessment and information sharing for suspected swallowed drugs.

    Verbatim wording from the response

    “In relation to the specific concern that individuals suspected of having swallowed drugs may not receive urgent medical attention or appropriate guidance upon release, I can confirm that the College’s Authorised Professional Practice (APP) on Detention and Custody provides clear and robust guidance. This includes:”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 7 March 2025

    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

    Review the Regulation 28 document to identify appropriate responses to incidents involving suspected drug ingestion.

    Verbatim wording from the response

    “The NPCC Stop & Search portfolio has reviewed the Regulation 28 document and will work to ensure officers are equipped to resolve incidents such as these in the most appropriate manner. The portfolio will work with other national policing portfolios and stakeholders, to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them.”

    Source location

    Response from National Police Chiefs' Council
    Page 1 · response
    Published 7 March 2025

    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

    Work with national policing portfolios and stakeholders to provide refreshed training and guidance on available policing powers.

    Verbatim wording from the response

    “The NPCC Stop & Search portfolio has reviewed the Regulation 28 document and will work to ensure officers are equipped to resolve incidents such as these in the most appropriate manner. The portfolio will work with other national policing portfolios and stakeholders, to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them.”

    Source location

    Response from National Police Chiefs' Council
    Page 1 · response
    Published 7 March 2025

    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 Authorised Professional Practice guidance is considered sufficient to address concerns about urgent medical attention and guidance for suspected swallowed-drug cases.

    Verbatim wording from the response

    “In relation to the specific concern that individuals suspected of having swallowed drugs may not receive urgent medical attention or appropriate guidance upon release, I can confirm that the College’s Authorised Professional Practice (APP) on Detention and Custody provides clear and robust guidance. This includes:”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 7 March 2025

    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

    Police currently lack power to convey a person detained under these provisions to hospital against their wishes.

    Verbatim wording from the response

    “As noted within the Authorised Professional Practice, there is clear guidance for what Custody Officers should do, when presented with a detainee who is suspected of having packed or swallowed drugs. I agree with your observations that there is a material difference between the action taken for those arrested, and those who are not. Further to this there is currently no power for officers to convey to hospital somebody detained under these provisions against their wishes. Whilst custody is heavily regulated with law, policies, procedures and best practice, fundamentally, an officers primary role is to preserve life and the risks in such cases should be recognised and further mitigated.”

    Source location

    Response from National Police Chiefs' Council
    Page 1 · response
    Published 7 March 2025

    Open published response
  2. Inner North London

    AI-generated summary

    Jeroen ENSINK · 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

    Dr Jeroen Ensink was stabbed to death in a wholly unprovoked attack on 29 December 2015. The report identified multiple concerns involving police recording and information-sharing failures, including failures to identify and communicate possible mental health problems and issues in the handling of evidence and custody records.

    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 refer detainees for forensic medical examination on relevant non-substance grounds

    Wider context from the report

    “10. The custody sergeant gave evidence that, had it not been for suspected cannabis use, he would not have called the FME for any other reason. ”

    Source location

    Jeroen ENSINK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Coventry

    AI-generated summary

    Mark Adam Yafai · 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

    Mark Adam Yafai was arrested in the early hours of 1 July 2015 after disclosing recent cocaine use, and was found convulsing and frothing at the mouth in his cell. He suffered cardiac arrest and died at hospital; the stated cause of death was acute cocaine toxicity. The report raised concerns that custody policies used unclear terminology and gave too much discretion over healthcare assessment, risk assessment and observation for detainees who had disclosed drug use.

    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

    Lack of clear and consistent drug-related risk assessment and observation guidance

    Wider context from the report

    “i. The Safer Detention Policy and Handling of Person in Custody Composite Policy as updated August 2014 was replaced by the WMP Detention and Custody Policy Inc. Standard Operating Procedure with effect from the 22nd December 2015. The earlier policy was in operation at the time Mark Yafai died. The earlier policy lacked clarity or guidance in how the phrase “under the influence” must be interpreted. The phrase is unsuitable since it confers a very broad discretion upon a custody officer to not have the detainee examined by a Health Care Professional, despite a detainee has disclosed recently consuming drugs. The impact upon risk assessment and levels of observation is clear and significant. A broad discretion of an officer when determining risk concerning medical matters including drug use is inadequate. The jury made a determination in similar terms. ii. The evidence was the policy is accessible. Accordingly, it is paramount that the policy must provide clear unambiguous guidance/ direction to custody officers particularly in relation to drugs which can have serious consequences for an individual who has consumed. The circumstances of this inquest touching upon the death of Mark Yafai accentuated this point. The evidence was that cocaine can have toxic effects even from small quantities (as little as 0.03g). Consumption can be via a number of means and the effects delayed depending upon the method of ingestion. There is no antidote to cocaine toxicity. The evidence was custody officers range of knowledge about drugs and the effects can and do differ and this can have a bearing upon risk assessment given the terminology in the policy and broad discretion officers have. iii. The 2015 policy retains that same unclear terminology i.e. “believed to be under the influence of drugs or withdrawing from drugs” and “will be seen by a Health Care Professional (HCP) as a matter of course”. iv. It does not deal with the instances in which a detainee irrespective of presentation (which is not itself any easy assessment when a detainee is being observed by an officer most likely for the first time with no information against which a comparison may be made as whether their current presentation is indeed “normal”) has disclosed the recent consumption of drugs. What is “a line” or any quantitative opinion on drugs consumed is a very subjective assessment by the detainee and/ or the custody officer. v. An assessment as to the effect of any drugs is best assessed a by a Heath Care Professional. That was the evidence and information that emerged in the inquest. Standard medical observations can be undertaken ranging from a check as body temperature to elevated heart rate or blood pressure which may be indicators that drugs are having an adverse effect upon the body. vi. Earlier identification of these matters may prevent death particularly since treatment for many drugs, particularly cocaine, is symptomatic. Close observation of a detainee is clearly significant since early treatment of symptoms can have an impact upon an individual’s survivability. vii. The policy in other respects does use directional/ non discretion type terminology in some respects when dealing with drug issues. It is thus currently inconsistent in this respect on this topic and in interrelation with Risk assessment and appropriate observation levels which are a focus of custody personnel. ”

    Source location

    Mark Adam Yafai · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. South Yorkshire (Western)

    AI-generated summary

    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.

    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 call a health professional for alcohol- or drug-dependent detainees

    Wider context from the report

    “(17) PACE requires a health professional to be called if the detainee is dependent on alcohol or drugs. This did not take place. ”

    Source location

    Neil Budziszewski · Prevention of Future Deaths report
    Page 2 · 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

    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
    Page 3 · 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

    Failure to arrange direct doctor engagement with a non-cooperative detainee

    Wider context from the report

    “(21) It is accepted that Mr Budziszewski was asked at this stage if he wanted to see a doctor and admitted. However, expert evidence was given that this was unwise and the doctor should have been asked to engage with the prisoner as this was likely to have resulted in co-operation. ”

    Source location

    Neil Budziszewski · Prevention of Future Deaths report
    Page 4 · 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

    Failure to consider healthcare referral for medically vulnerable detainees

    Wider context from the report

    “(10) There was no consideration given at that time to calling a health care professional, notwithstanding the information gained which included that Mr Budziszewski was an alcoholic and was a prescribed methadone user. The view seems to have been taken that the medical provider would simply refuse to see a detainee until they were no longer in drink. This carries considerable dangers if the detained person’s condition was not actually caused by drink but by a head injury or hypoglycaemic state etc. ”

    Source location

    Neil Budziszewski · Prevention of Future Deaths report
    Page 3 · 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

    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
    Page 4 · response
    Published 23 March 2015

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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
    Page 6 · response
    Published 23 March 2015

    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

    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
    Page 3 · response
    Published 23 March 2015

    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

    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
    Page 3 · response
    Published 23 March 2015

    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

    Include medical-referral responsibilities in the Inspector guidance pack and remind substantive Inspectors of the referral requirement.

    Verbatim wording from the response

    “Although the medical referral would be the responsibility of the custody staff, the Inspector has a role to play in requesting the medical referral where, upon review, he or she believes it is necessary. This will all be included within the pack that will be provided to Acting and Temporary Inspectors. Substantive Inspectors will be reminded of this requirement by 31 May 2015.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 5 · response
    Published 23 March 2015

    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

    The detainee was not displaying symptoms or circumstances requiring healthcare professional consultation while at Bridge Street custody.

    Verbatim wording from the response

    “In relation to the requirement to call a doctor for alcohol related matters in custody, there are five criteria where a healthcare professional must be consulted, three of those relate to alcohol issues:-”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 2 · response
    Published 23 March 2015

    Open published response
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Data last updated 7 September 2026