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During the course of 2022, HMICS and HIS collaborated on a baseline review of the provision of healthcare services to police custody centres across Scotland. A report outlining our findings and recommendations was published in January 2023. We used learning from the review to develop a framework to inspect healthcare provision within police custody, and to devise a methodology for the joint inspection of police custody centres.
Following completion of the baseline review, we commenced a programme of joint custody inspections and, to date, have published nine custody inspection reports. The findings from these can be found on our website. In March 2025 we published a revised version of our custody inspection framework, which can be found here. It outlines the quality indicators that form the basis of our custody inspections.
This report relates to our inspection of St Leonards custody centre, the primary custody facility serving Edinburgh division, alongside Midlothian and East Lothian within the Lothians and Scottish Borders division. The inspection was carried out jointly by HMICS and HIS and focused on assessing the treatment of, and conditions for, individuals detained in police custody, as well as the effectiveness of custody operations and healthcare provision.
The onsite phase of the inspection took place in September 2025. Inspectors examined Police Scotland National Custody System (NCS) records and reviewed a representative sample of detainees processed during August 2025. We assessed the physical environment, including cells and healthcare facilities, and observed key custody processes. Inspectors also engaged directly with detainees, custody staff and healthcare professionals.
The inspection identified a number of findings consistent with themes emerging from previous custody inspections. We have referenced these within the body of this report where relevant. In particular, concerns remain around consistency in recording on the NCS, including significant gaps in the documentation of observations, meals, handovers, healthcare interactions, care planning and legal rights. In some cases, care plans did not adequately reflect assessed risks, and delays in recording observations persisted.
We found widespread reliance on generic, copy and paste entries which undermined the quality, reliability and value of custody records. Although strengthened scrutiny arrangements, including the creation of a new CJSD audit and compliance post, were acknowledged, overall audit coverage remained limited in relation to national custody throughput.
The centre had clear staffing challenges and, as outlined within our report, these can impact on the effectiveness and timely completion of routine custody tasks. Limited management visibility was also raised by staff, with implications for oversight of custody centre operations.
There was evidence of improvement in the management of children in custody, with no children placed in cells and no unnecessary detention following decisions to release. This reflects significant progress and presents an opportunity for the sharing of good practice across the custody estate relevant to the approach taken at St Leonards.
The report makes a series of recommendations aimed at improving operational effectiveness, recording standards, risk management, confidentiality, and governance arrangements. It also includes a number of healthcare-specific recommendations addressing training compliance, infection prevention and control, medicines management and the custodial care environment. These recommendations are directed at both Police Scotland and NHS Lothian.
We wish to thank the officers and staff from CJSD and local policing, as well as staff from NHS Lothian responsible for the delivery of healthcare at the centre.
The custody inspection programme is overseen by Ray Jones, Lead Inspector at HIMCS, with support from HMICS Associate Inspectors and HIS Inspectors.
Craig Naylor
His Majesty’s Chief Inspector of Constabulary
May 2026