First reported 23 Mar 2015•Latest report 27 Mar 2024
Definition
What this concern includes
Includes failures in training, induction, supervised practice, competence assessment, refresher provision and remediation of identified training deficiencies for personnel working in police custody suites, including custody staff and healthcare professionals, where these controls are intended to support safe custody-suite work.
Not included
Excludes generic police, prison or healthcare training deficiencies without an explicit police custody-suite work context.
Excludes failures in custody-suite culture, leadership, staffing capacity, call handling or clinical assessment where staff competence or training is not the shared unsafe condition.
Excludes competence or training concerns for personnel who do not work in police custody suites.
Excludes failures occurring after relevant staff have been reliably trained and their competence assured, where the remaining problem is a separate operational or clinical control.
Reports
6
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2015–2024
First to latest report issue date
Stated actions
24
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.
Department of Health and Social Care2
Home Office2
National Police Chiefs’ Council2
NHS England2
South Yorkshire Police2
Birmingham and Solihull Mental Health NHS Foundation Trust1
G4S1
HCRG Care Services Ltd1
Ministry of Justice1
Nestor Primecare Services Limited1
Staffordshire Police1
West Midlands Police1
Ministerial department4
Police force4
Executive non-departmental public body2
National policing body2
Independent healthcare provider1
NHS trust1
Prison operator1
Private limited company1
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.
South Yorkshire (Western)
Concerns raised1
Lack of mandatory or refresher police officer training in constant observations
This report raised 8 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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Deliver scenario-based training on Acute Behavioural Disturbance, positional asphyxia, safer restraint and continuous observation of restrained subjects.
Stated by South Yorkshire PoliceStated completedThe respondent said that this action was complete when they made their response on 4 April 2024.
Derby and Derbyshire
Concerns raised1
Lack of sufficient training for health care professionals working in police custody suites
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Developed and published recommendations and guidance supporting education and supervised training in forensic medicine, including police custody healthcare.
Stated by Faculty of Forensic & Legal Medicine of the Royal College of Physicians of LondonStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Action
Contacted members through a bulletin to highlight the report and reaffirm the importance of initial and continuing education and supervised training.
Stated by Faculty of Forensic & Legal Medicine of the Royal College of Physicians of LondonStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Action
Review and develop the two-day foundation training materials into an interactive learning experience for newly recruited healthcare professionals.
Stated by CRG Medical ServicesStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Extend foundation training for newly recruited healthcare professionals from two days to five days.
Stated by CRG Medical ServicesStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
Action
Train Clinical Leads and senior healthcare professionals in presentation skills to improve consistency and quality during foundation training.
Stated by CRG Medical ServicesStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
Action
Require new recruits to complete foundation training and obtain Clinical Lead-approved certification before undertaking clinical shifts.
Stated by CRG Medical ServicesStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
Action
Provide five intensive-supervision shifts for new recruits, with role-specific expectations, senior HCP feedback and Clinical Lead sign-off before completing induction.
Stated by CRG Medical ServicesStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for ensuring forensic clinicians receive senior advice rests with the clinician and employer.
Stated by Faculty of Forensic & Legal Medicine of the Royal College of Physicians of LondonRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West London
Concerns raised1
Lack of adequate mental health training for Custodial Nurse Practitioners seeing high-risk and complex patients in police custody
This report raised 2 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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Work with NHS England and other stakeholders to deliver a fit-for-purpose police custody healthcare service specification.
Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 6 October 2023.
Action
Provide the latest draft National Healthcare Specification, including requirements for governance, qualifications, competency assessment and clinical supervision.
Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 6 October 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Responsibility for custodial nurse practitioners in police custody settings lies with the Police Chiefs’ Council, not NHS England.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The NPCC response addresses the remaining content of the first matter of concern.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The national healthcare specification adequately addresses custody healthcare qualifications, competency, supervision and training for doctors, nurses and paramedics.
Stated by National Police Chiefs’ CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised1
Insufficient understanding of the L&D police custody suite model’s role and limitations
This report raised 6 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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10
Action
Discuss interagency responsibility and information-sharing for mentally unwell people in custody at the next JSOG meeting.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Develop and publish a weekly bulletin explaining the Liaison and Diversion Service’s role and limitations.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Present the respective PCHS and L&D responsibilities for mental health crises at the NPCC Custody Forum Conference.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Commission and publish a career and competency framework defining L&D roles and required competencies.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Discuss cross-agency information sharing and clarify Liaison and Diversion Service responsibilities at the Joint Strategic Operational Group meeting.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Publish a weekly bulletin explaining the Liaison and Diversion Service’s role and limitations to improve internal understanding.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Provide frontline staff with clear advice on the nature, scope and limitations of the current Liaison and Diversion function.
Stated by West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Present the respective PCHS and L&D responsibilities for mental health crises at the NPCC Custody Forum Conference.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Continue collaborative work with Police and Crime Commissioner counterparts to align PCHS, Liaison and Diversion specifications, responsibilities and locally commissioned services.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Provide all frontline staff with clear advice about the nature, scope and limitations of the current Liaison and Diversion function.
Stated by West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Custody staff may rely on and defer to qualified healthcare practitioners for mental and physical health assessments.
Stated by West Midlands PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
It would not be practicable for NHS England to commission a service to take on the Police Custody Healthcare Service role.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Insufficient targeted training on drug and alcohol-related risks in custody
This report raised 5 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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Secure force training on drug and alcohol risks, including methadone intoxication and alcohol withdrawal.
Stated by Staffordshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2015.
Action
Provide mandatory first-aid induction training, including defibrillator, advanced airway, drug and alcohol risk training, with annual refresher training for detention officers.
Stated by G4S Care And Justice Services (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 15 April 2015.
Action
Examine opportunities to provide additional drug and alcohol risk guidance through an online learning management system.
Stated by G4S Care And Justice Services (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 15 April 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing guidance and training already address drug and alcohol risks, withdrawal, and referral for medical assessment where concerns arise.
Stated by College of Policing and DCC Nick EphgraveExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Yorkshire (Western)
Concerns raised2
Custody-suite training failing to provide adequate preparation
Lack of training for custody-record reviewing inspectors
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review Acting Inspector custody-review training and develop a protocol, guidance pack and associated electronic review materials.
Stated by South Yorkshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 23 March 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing custody training and practices comply with Home Office standards; the identified failures were attributed to individual officer error rather than deficient arrangements.
Stated by South Yorkshire PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures in training, induction, supervised practice, competence assessment, refresher provision and remediation of identified training deficiencies for personnel working in police custody suites, including custody staff and healthcare professionals, where these controls are intended to support safe custody-suite work.
