PFD report

Wayne Spencer Malcolm Broad · Prevention of Future Deaths report

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Issued 17 Jan 2014•North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
5

Named on the report

Responses found
3

Of 5 recipients

Stated actions
3

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised3

  1. Unavailability of specially trained nursing staff for hospital patients with substance misuse
    Part of recurring concern: Insufficient qualified healthcare staffing capacity
  2. Unavailability of a dedicated substance misuse team in police custody suites
    Part of recurring concern: Insufficient dedicated substance-misuse support in custody
  3. Failure of SERCO handcuffing policy to align with ACPO guidance for seriously ill detainees
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    The presence of a specialist substance-misuse nurse would not have produced a different outcome in this case.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unavailability of specially trained nursing staff for hospital patients with substance misuse

Wider context from the report

“(3) Specially trained nursing staff should be available at hospitals for dealing with patients with substance misuse. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unavailability of a dedicated substance misuse team in police custody suites

Wider context from the report

“(1) That was no dedicated substance misuse team available to look after Mr Broad when he was in the custody suite at Hatfield Police Station, as there would have been had Mr Broad been detained in prison. ”

Is this part of a recurring concern?

Yes — Insufficient dedicated substance-misuse support in custody.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of SERCO handcuffing policy to align with ACPO guidance for seriously ill detainees

Wider context from the report

“(2) Police are required to make risk assessments and have requirements when dealing with the handcuffing of seriously ill detainees. There should be alignment with particular regard to those who are seriously ill and in general SERCO policy should come into alignment with ACPO guidance on the use of handcuffs. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 presence of a specialist substance-misuse nurse would not have produced a different outcome in this case.

Verbatim wording from the response

“In this case the patient was admitted with a life threatening condition needing emergency intervention. The effect of long term alcohol abuse and associated complications led to the need for emergency resuscitation. The role of a specialist substance misuse nurse would in contrast involve making an assessment of the patient and determining the best options in terms of referral or appropriate care pathway. In this case I do not feel that the presence of a specialist substance misuse nurse would have led to a different outcome for Mr Broad.”

Source location

2014-0020-Response
Page 3 · response
Published 17 January 2014

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 risk assessments and handcuffing protocols are outside the Department of Health’s remit.

Verbatim wording from the response

“• Police are required to make risk assessments and have protocols for dealing with the handcuffing of seriously ill detainees. SERCO policy should align with ACPO guidance on the use of handcuffs”

Source location

2014-0020-Response
Page 2 · response
Published 17 January 2014

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

Routine specialist substance-misuse nurses are unnecessary because registered nurses, multidisciplinary teams and established care pathways provide appropriate care.

Verbatim wording from the response

“You suggest in your third point that specially trained nursing staff should be available in hospitals for dealing with patients with substance misuse. I do not however consider that such specialist nurses should routinely be available in all hospitals.”

Source location

2014-0020-Response
Page 2 · response
Published 17 January 2014

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

Local commissioners are responsible for determining specialist substance-misuse nurse provision according to assessed local need and resources.

Verbatim wording from the response

“However, the provision of specialist substance misuse nurses is a matter for local commissioners to determine based on an assessment of local needs. There may be some hospitals where the resources required to make this facility available would be justified but, where there are very few presentations from patients with substance misuse problems, providing such a service might not be the most effective use of available resources.”

Source location

2014-0020-Response
Page 2 · response
Published 17 January 2014

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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

The current contract does not provide for dedicated substance misuse teams at police stations.

Verbatim wording from the response

“G4S Forensic and Medical Service are responsible for the provision of medical services to Hertfordshire Police as defined in a specific contract written by Hertfordshire Police (“the Contract”), which does not at this time, provide for putting a dedicated substance misuse team into each of the police stations served by the Contract. Rather, the Contract requires us to provide medical staff to deal with a wide range of issues from the confirmation of death, intimate examinations of victims of sexual assault, advice on medical issues across a wide spectrum of circumstances and the provision of face to face clinical treatment of those detained in custody.”

Source location

2014-0020R2_Redacted
Page 1 · response
Published 17 January 2014

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

A dedicated substance misuse team in police custody is not viable because police forces lack the facility and detention costs and timescales are prohibitive.

Verbatim wording from the response

“I note your recommendation that Hertfordshire ought to have a substance misuse team available at the police station, similar to that which would be provided within the Prison Service. Unfortunately this is not a facility that police forces have available; the cost and relatively short timescales of police detention mean this is not a viable or cost effective option for forces. We do however take our duty of care for the welfare of detainees very seriously and provide medical care in custody which effectively triages our detainees to assess that they are fit to be detained and are kept safe.”

Source location

2014-0020R3_Redacted
Page 1 · response
Published 17 January 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Transfer commissioning responsibility for police-custody healthcare to NHS England under NHS care standards.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 17 January 2014.
  2. 2

    Support the transfer of police custodial healthcare commissioning to the NHS.

    Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 17 January 2014.
  3. 3

    Participate in the Police Healthcare Oversight Board to oversee the commissioning transition.

    Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 17 January 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Timely and appropriate clinical advice within the existing contract is considered sufficient to meet Hertfordshire Police’s current needs.

    Stated by G4S Forensic & Medical Services (UK) LtdExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Transfer commissioning responsibility for police-custody healthcare to NHS England under NHS care standards.

Verbatim wording from the response

“The responsibility for healthcare in police custody suites will however soon transfer from individual police authorities to NHS England. Healthcare for persons in police custody will therefore be commissioned to NHS standards of care. This should lead to more consistent and improved healthcare standards, by ensuring that the same range and quality of substance misuse services are available to persons in police custody as would be available in prison or community settings. An individual requiring a clinical intervention for substance misuse will receive one.”

Source location

2014-0020-Response
Page 2 · response
Published 17 January 2014

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

Support the transfer of police custodial healthcare commissioning to the NHS.

Verbatim wording from the response

“However, in this arena things are changing rapidly. You will be aware Lord Bradley undertook a review of mental health and the justice system in 2009 and one of his recommendations was to transfer the commissioning responsibility for police custodial healthcare to the NHS. The national police Custody business portfolio support the current work in English forces to undertake this transfer and sit at the national Police Healthcare Oversight Board, jointly chaired by Home Office and Department of Health to oversee the transition. The legislative change for this is set for April 2015.”

Source location

2014-0020R3_Redacted
Page 1 · response
Published 17 January 2014

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

Participate in the Police Healthcare Oversight Board to oversee the commissioning transition.

Verbatim wording from the response

“However, in this arena things are changing rapidly. You will be aware Lord Bradley undertook a review of mental health and the justice system in 2009 and one of his recommendations was to transfer the commissioning responsibility for police custodial healthcare to the NHS. The national police Custody business portfolio support the current work in English forces to undertake this transfer and sit at the national Police Healthcare Oversight Board, jointly chaired by Home Office and Department of Health to oversee the transition. The legislative change for this is set for April 2015.”

Source location

2014-0020R3_Redacted
Page 1 · response
Published 17 January 2014

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

Timely and appropriate clinical advice within the existing contract is considered sufficient to meet Hertfordshire Police’s current needs.

Verbatim wording from the response

“Whilst I fully accept that any service provision could be enhanced, G4S provide an efficient and effective service within the confines of a contract provided by a public body that, in turn, is suffering from the general reduction of funding experienced over the last few years. By ensuring that timely and appropriate advice is given I am satisfied that we meet the needs of Hertfordshire Police as they currently stand and in accordance with the Contract.”

Source location

2014-0020R2_Redacted
Page 2 · response
Published 17 January 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
3/5

Data last updated 7 September 2026