Custody inspection report - Edinburgh

119. This section sets out the findings from Healthcare Improvement Scotland’s (HIS) visit to St Leonards police custody centre on 30 September 2025. It includes an outline of current healthcare provision and identifies any areas of good practice and recommendations for improvement to help drive the quality of care and consistency in healthcare delivery. The inspection of healthcare focused on the health and wellbeing aspects of detainees as set out in the joint HIS/HMICS Framework to Inspect. The framework has been developed using a human rights-based approach which includes person-centred indicators. All components of the Optional Protocol to the Convention against Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment are reflected in our inspection methodology.

How we carried out the inspection

120. The inspection was unannounced, however, to enable the NHS Lothian to undertake preparatory work, we provided the board advance notice that an inspection would take place at a future date.

121. During the inspection, HIS inspectors spoke with members of staff from healthcare as well as Police Scotland custody staff, and reviewed the care environment within the police custody centre. Inspectors also spoke with a small number of detainees during the inspection regarding their experience of healthcare. The onsite inspection team consisted of two inspectors and a Pharmacy Subject Matter Expert who provided support to the inspection team. Subject Matter Experts are individuals who join our inspection team to provide specialist healthcare opinion based on their area of expertise. Working under the direction of the lead inspector, the Subject Matter Expert is responsible for ensuring that their opinion of the healthcare being delivered during the inspection is informed by current practice, professional knowledge and experience.

122. We asked NHS Lothian to provide key evidence documents, and we held a teleconference with healthcare staff following the onsite visit to help inform our inspection findings.

Governance of Healthcare

123. St. Leonards sits within NHS Lothian, with healthcare delivered by the Southeast Scotland Police Custody Healthcare and Forensic Examination Service. This nurse-led service operates peripatetically across multiple custody centres, ensuring 24/7 coverage. Leadership is provided by a Clinical Nurse Manager (CNM).

124. Staffing levels were stable with no vacancies. However, at the time of inspection, the service was managing a high level of sickness absence effectively through internal escalation and flexible staffing arrangements. The team comprised both Adult Health Nurses (RGNs) and Registered Mental Health Nurses (RMNs), supported by Senior Charge Nurses (SCN) and on-call Forensic Physicians. Enabling responsive, needs-based care, this is considered good practice.

125. Healthcare management and oversight was provided through NHS Lothian’s Royal Edinburgh Hospital and Associated Services (REAS) governance structures. Twice-daily staff huddles, that included NHS Lothians courts liaison service supported safe and coordinated care by enabling timely information sharing and joint decision-making for vulnerable individuals. This is considered good practice. Regular engagement with Police Scotland and structured governance meetings ensured accountability and service alignment.

126. The service demonstrated a proactive approach to quality assurance, completing audits and collecting data on different aspects of care delivery, including mental health assessments and harm reduction interventions. This data was discussed regularly at meetings within the REAS governance structure. This is considered good practice.

127. All staff had completed induction training, which included trauma-informed practice. While human rights-based training was also reported as completed by all staff, compliance with other mandatory training topics was variable. It is essential that staff are up to date with their mandatory training so that they can carry out their role safely and effectively.

128. The majority of staff had up-to-date Personal Development Plans (PDPs) and appraisals, reflecting a positive culture of professional development.

129. Not all nurses working in police custody had received training in Dried Blood Spot Testing (DBST), which was delivered by the NHS Lothian Blood Borne Virus (BBV) team. We were informed that dates for future training were being arranged. Although DBST was available, most of the testing was carried out via venepuncture, a method that can be more difficult to deliver in custody settings due to time constraints and clinical requirements. Additionally, some detainees may be reluctant to undergo blood testing, which could further impact uptake.

130. Five DATIX (risk management information system) reports were submitted in the past year, with learning shared through team meetings. Information on how to give feedback or make a complaint was displayed. No complaints had been received in the past year.

131. Although there was no dedicated Infection Prevention and Control (IPC) lead at St. Leonards, NHS Lothian’s IPC team provided consistent and effective support through regular governance meetings and timely access to expert advice. All staff had completed IPC training, which was monitored and kept up to date, ensuring staff practiced in line with national standards. Local IPC audits were conducted regularly and mirrored NHS Lothian’s audit programme, enabling IPC practice and the care environment to be monitored and also support continuous improvement. The National Infection Prevention and Control Manual (NIPCM) was readily accessible via the staff shared drive.

132. The treatment room was visibly clean, with clear responsibilities for cleaning tasks. The most recent IPC audit did not identify any issues with the environment. However, the audit process was ineffective as damage was clearly visible to the walls, flooring and to woodwork around the hand wash basin in the treatment room. This damage would not support effective cleaning and decontamination posing a potential IPC risk. It was unclear from speaking with healthcare staff if this damage had been reported to custody supervisors as responsibility for carrying out repairs to the environment, including the treatment room, lies with the custody division.

133. Care equipment was cleaned between patient use. Hand hygiene facilities were available, and PPE was easily accessible and appropriately stored.

134. Sharps bin disposal was compliant. Clinical waste bags were stored in a locked bin awaiting uplift. However, the bin was in a publicly accessible car park and was not secured, posing a safety and security risk. No linen was used by healthcare staff.

135. Emergency equipment and medications were available, in date, and subject to daily checks. Systems were in place for managing urgent care and minor injuries. Staff had access to Immediate Life Support training, however compliance with the completion of training was low. We were told that this was due to limited availability of training courses. Plans were in place for staff to attend upcoming courses.

Access to healthcare

136. Healthcare needs were identified via a vulnerability questionnaire completed by custody staff. Referrals to healthcare were made based on detainee responses, and detainees could also self-request healthcare at any time.

137. There was no national standard for healthcare assessment waiting times in custody. In the Southeast cluster, all referrals were routed through REAS’s central hub, allowing monitoring of referral volumes and patterns. Referrals were electronically triaged by nurses, with waiting times influenced by detainee volume, triage outcomes, and nurse location.

138. General healthcare information was included in the ‘your rights when you are at the police station’ document, and was available in an easy-read format. This is considered good practice.

139. Assessments were generally conducted in the treatment room. We were told by custody staff that they preferred the door open for safety reasons. However, it was closed upon request of healthcare staff or patients to preserve dignity and confidentiality.

140. Custody and NHS staff used separate systems to record custody data, which were not compatible. Custody staff use the National Custody System (NCS) to record information relevant to detainees, whereas NHS staff use Adastra.⁴ Relevant healthcare information and recommendations were emailed to custody staff and then manually entered onto the NCS by custody staff. Additionally, both health and police custody staff were able to provide verbal updates on the patients.

141. NHS staff followed appropriate procedures for documenting injuries allegedly caused by force.

142. All cells were wheelchair accessible, with one adapted for patients with mobility needs. For detainees with complex care needs, a fitness to remain in custody assessment was conducted by a nurse, followed by joint decision making with Police Scotland, this is considered to be good practice.

143. Harm reduction information and resources were available during healthcare interactions.
Medicines management

144. Governance and oversight was in place for medicines management across the southeast cluster, including St Leonards. A clinical pharmacist was available to provide support and advice.

145. Staff were able to describe the systems and processes in place for medicines management. Standard Operating Procedures (SOP) were in place to support the safe supply, storage, dispensing, and destruction of medicines. However, the SOPs described differing approaches to medicines management and at times did not reflect the practices described by healthcare staff.

146. A process was in place for ordering medications, including controlled drugs. Healthcare staff reported that NHS Lothian’s Controlled Drugs Governance Team visits custody centres to safely destroy expired or unused controlled drugs. Controlled drugs registers were well maintained, and the controlled drugs license was in the process of being renewed.

147. The service had effective systems for stock rotation and expiry date checks. All drugs reviewed during the inspection were in date.

148. Robust medication reconciliation was carried out using electronic records and patient interviews. This ensured patients received their usual medications while detained, including Opiate Substitution Therapy (OST).

149. Most nurses were non-medical prescribers and prescribed all medications, including controlled drugs. Prescriptions were recorded on Adastra. NHS Lothian had reviewed its prescribing processes and governance following previous communication from Healthcare Improvement Scotland regarding the safe prescribing and administration of medicines within the provision of police custody suites.

150. Medications (excluding OST) were dispensed into multi-compartment compliance aids to support custody staff with administration. Handwritten administration guidance and information regarding the medicines was recorded on the compliance aids. This could pose a potential risk due to the variability in labelling and a lack of warnings or guidance. Custody staff received email instructions regarding medicines administration from healthcare staff. OST was dispensed directly by nurses.

151. A process was in place for patients to receive nicotine replacement therapy patches if requested.

Substance use

152. Custody staff used a vulnerability questionnaire that included questions on alcohol and substance use, including dependency. Nursing staff assessed detainees showing signs of intoxication or withdrawal, using appropriate tools to monitor symptoms, conducting physical observations, and prescribe detoxification medication when needed.

153. The Scottish Government’s Medication-Assisted Treatment (MAT) standards, introduced in April 2022, aim to ensure consistent, high-quality drug treatment across Scotland. NHS Lothian had developed a draft SOP for applying MAT within police custody healthcare and court liaison services.

154. The SOP acknowledged the current limitations in fully meeting MAT Standard 1, which related to initiating treatment on the same day as presentation. This standard presented particular challenges in all police custody settings due to operational constraints, such as prescribing authority, staffing availability, and the need for clinical assessment within secure environments. Despite these limitations, the SOP outlined clear referral pathways to community services and provisions for short-term OST prescribing to manage withdrawal symptoms.

155. The ability to deliver all aspects of the MAT standards had been actively discussed at both regional and national levels, with staff from the REAS contributing to Medication-Assisted Treatment Standards Implementation Network (MATSIN) groups. While national agreement on the interpretation and application of MAT standards in custody settings was still pending, the ongoing review and standardisation of implementation processes represented a positive step. These efforts support staff in delivering consistent, clinically appropriate care to individuals in custody who require medication-assisted treatment.

156. Where a person was established on OST, there were processes to obtain and maintain prescriptions where possible. Any delay in this required assessment for a substitute short term medication to prevent withdrawals and contact with the person’s community services. There was a clear process within a referral pathway.

157. Naloxone was available and administered by nursing staff when on site. There were police officers on site trained to carry naloxone.

Mental health

158. All nurses used a standardised approach to health assessments, including mental health, which covered patient history, examination findings, and recommendations. Clear guidance was in place for completing assessments, with details recorded on Adastra.

159. Where concerns were identified, risk management plans were shared with custody staff, including enhanced monitoring or observation levels.

160. The on-duty healthcare team was responsible for initial mental health assessments, as outlined in the East of Scotland pathway. If same-day or emergency psychiatric assessment was required, referrals could be made to the Orchard Clinic for attendance by the duty Forensic Psychiatrist or, out-of-hours, to the Adult Psychiatry Specialist Registrar. Staff from both healthcare and custody spoke positively about strong links with the Forensic Psychiatry Service. Good access to psychiatric expertise enabled timely decision-making, supported accurate diagnosis, and ensured that individuals in custody receive appropriate and responsive mental health care, particularly in complex or high-risk situations.

161. In addition to assessing fitness for interview or court, the service supported care planning and transfer arrangements for individuals detained under the Mental Health (Care and Treatment) (Scotland) Act 2003.

162. Custody data showed that St Leonards was not used as a place of safety under Sections 297 and 298 of the Act in 2024, this may indicate that appropriate pathways were followed to avoid unnecessary custody for mental health assessments.

163. Arrangements were in place for young people in custody with mental health needs. Where concerns were raised or fitness to release required assessment, referrals could be made to the Child and Adolescent Mental Health Service (CAMHS) at Edinburgh Children’s Hospital.

164. Detainees with learning disabilities were identified through the vulnerability questionnaire and the vulnerable persons database. Systems were in place to involve an Appropriate Adult service when required.

Pre-release pathways and referrals

165. Good processes for onward referral were evident, with a wide range of statutory and third-sector support services clearly displayed for staff.

166. We saw evidence of detainees being signposted to community services. Custody staff were knowledgeable about available support, and a range of leaflets covering mental health, substance use, wellbeing, harm reduction, peer support, and family support were accessible.

167. When a detainee was transferred to court, a Person Escort Record (PER) form was completed, including medical and medication details sourced from NCS.

168. Both nasal and injectable forms of naloxone were offered to patients on release. Although uptake was low, data indicated that it was being offered, which was a positive finding. Staff told us that the increased access to naloxone in the community was a common reason detainees frequently gave for declining it. It was positive that naloxone continued to be offered, and uptake was monitored to inform service delivery.

Local Policing

169. Inspectors spoke with officers from Local Policing who stated they considered their custody colleagues to be very helpful and accommodating.

170. It was acknowledged that there could be some tensions between operational officers and custody staff emanating from the length of time taken to process detainees. Local policing officers cited instances where detainee processing was overly long and arduous, where lengthy queues could form.

171. Officers remarked there are rarely sufficient custody staff to run three charge bars and the impact on operational policing can be substantial, particularly at peak times.

172. Officers acknowledged the existing challenges with staffing resilience at the centre, highlighting that this undoubtedly had a negative impact on custody capability and staff morale.

173. Custody supervisors stated that local policing officers often struggle with the interpretation of the Criminal Justice Act 2016, and will regularly challenge custody decisions. The CJSD recognises that a training course on the legislative provisions of the Act will be required to reduce or eliminate misinterpretation and provide a wider understanding of implications for custody. Plans are being developed by CJSD to introduce related training.