Custody inspection report - Highland and Islands

Governance of healthcare

151. Police custody healthcare in the Highland area is delivered by NHS Highland and governed by its Mental Health Directorate. This service supports police custody centres located at Burnett Road in Inverness, Fort William, and Wick.

152. In Inverness and Wick, the custody healthcare service is nurse-led with support from Forensic Medical Examiners (FME). Inverness benefits from 24/7 nursing coverage, while in Wick, the service is led by an Advanced Nurse Prescriber (ANP) who also serves as the Clinical Service Nurse Manager (CSM). This nurse also provided out-of-hours cover in Wick. FMEs are available on-call to support both locations.

153. In Fort William, healthcare provision was managed through a local general GP practice. FME cover was provided during the day by the GP practice, with an out-of-hours GP support available during evenings and weekends. The service demonstrated effective delivery for patients, with no notable gaps in provision identified during the inspection.

154. The ability to deliver a full range of healthcare services in Fort William was shaped by the current service model and the typically short duration detainees are held in custody. As Police Scotland generally do not detain individuals there for more than four hours, the FME provision had been designed to align with this low-throughput model of custody use. Where a detainee presents with complex or ongoing healthcare needs, and following assessment by the FME, they were transferred to Inverness custody centre, where onsite 24-hour access to healthcare services is available.

155. Healthcare delivery was effectively managed, underpinned by a robust and transparent governance framework. Oversight was maintained through clinical and care governance processes, including regular governance and multi-agency meetings between NHS Highland and Police Scotland.

156. Training records reviewed during the inspection showed good compliance with mandatory training and role-specific training, including modules on equality and human rights, the Istanbul Protocol, and trauma-informed practice. In Fort William, all new GPs were given the opportunity to shadow more experienced GPs attending the custody centre for learning and orientation.

157. Clinical supervision was conducted monthly by the Senior Charge Nurse (SCN), with staff also benefiting from peer supervision to reflect on complex cases. Structured meetings were held to discuss updates, concerns, and medication management. All FMEs received annual appraisals, with regular peer review meetings being held to discuss challenging cases.

158. Information on how patients could provide feedback or make complaints was clearly displayed in Inverness and Wick custody centres, however no information for patients was available in Fort William. Recommendation 5.

159. At the time of inspection, no complaints had been received in the previous 12 months. The DATIX system, a widely used incident reporting and risk management tool in healthcare settings, was used to report and manage incidents. These were reviewed in a timely manner during clinical governance meetings, with actions taken, outcomes monitored, and learning consistently fed back to staff to support continuous improvement.

160. NHS Highland was a key partner in the North of Scotland Forensics and Custody Healthcare Alliance, often referred to as the TAY initiative. This alliance included NHS Grampian, NHS Tayside, NHS Orkney, NHS Shetland, and NHS Western Isles, and was established to address the unique challenges of delivering consistent forensic and custody healthcare services across rural and remote areas. This is considered good practice.

161. As the most experienced and well-developed team within the alliance, NHS Highland has played a leading role in sharing knowledge and expertise across the region. This collaborative approach has been clearly evidenced during our inspection visits to other custody centres on the islands, where the influence of NHS Highland’s support and guidance was apparent.

162. The alliance promotes regional collaboration, peer support, and shared learning through virtual technologies and centres of expertise. It aims to enhance service quality, support staff development, and ensure alignment with national standards. As part of this commitment, the SCN and Clinical Nurse Manager (CNM) from NHS Highland dedicated protected time each week to support partner boards within the TAY initiative, contributing to the continuous improvement of patient care across the region.

163. Treatment rooms across the custody centres were visibly clean and well maintained. In Inverness and Wick, healthcare staff reported being responsible for cleaning surfaces, while Police Scotland cleaners managed the cleaning of the floors. An appropriate chlorine-based cleaning product was available in both Inverness and Wick, though it was not observed in Fort William. Blood and body fluid spillages were managed by an external contractor. Healthcare staff in Inverness described the standard of environmental cleaning as inconsistent, and concerns were raised through a clear and robust escalation process with custody staff. Repairs to the treatment room were also reported via custody staff, although staff in Inverness noted variable response times for the work to be carried out. In contrast, staff in Wick expressed satisfaction with the timeliness of repair work.

164. Care equipment was visibly clean and in good condition. Healthcare staff told us that it was cleaned daily and in between patient use. Hand hygiene facilities were available. In Inverness and Wick, PPE was available and appropriately stored; close to point of use and in a clean, dry area to prevent contamination. However, in Fort William although PPE was available, it was not stored appropriately; close to point of use and in a clean, dry area to prevent contamination. Recommendation 6.

165. Sharps bins used to dispose of used sharps, were correctly labelled with temporary closures in place in the custody centres in Inverness and Wick. However, sharps bins in Fort William were not signed or dated. Recommendation 7. Clinical waste was stored securely in a locked area and was disposed of in line with guidance.

166. No linen was used by healthcare staff in the custody centres.

167. During the inspection of Inverness custody centre, extensive refurbishment works were observed, including in areas adjacent to the treatment room. No HAI-Scribe^[9] assessment had been completed prior to the commencement of the works. Inspectors raised concerns as this may increase potential infection prevention and control (IPC) and health and safety risks to both patients and healthcare staff. These concerns were discussed with the Head of Service, CSM, and SCN.

168. In response, senior healthcare staff promptly arranged a joint IPC and health and safety visit to the custody centre on the same day. Following this visit, the treatment room was temporarily closed, and healthcare delivery was relocated to an alternative area within the custody centre. This ensured that care could continue safely while appropriate IPC and health and safety measures were implemented. A retrospective HAI-Scribe was subsequently completed. Recommendation 8.

169. We saw that external IPC and health and safety inspections were carried out at Inverness and Wick every year, however, these inspections did not take place at Fort William custody centre. We saw that there was an established programme of local audits based on Standard Infection and Control Precautions at Inverness custody centre. However, there were no local IPC audits being completed at Wick or Fort William. Recommendation 9.

170. Staff spoken with described the NHS Highland IPC Team as supportive and responsive. The National Infection Prevention and Control Manual (NIPCM) was available on the staff shared drive. Training records showed that all nursing staff had completed IPC training.

Access to healthcare

171. When people were brought into custody their healthcare needs were identified through a vulnerability questionnaire completed by Police Scotland custody staff. The questionnaire identifies physical health needs, long term conditions, mental health issues and those at risk from substance use. The information provided by the detainee when completing the vulnerability questionnaire may result in a referral to healthcare staff.

172. Although custody staff reported satisfaction with healthcare response times, the absence of a system to record actual waiting times, limited the service’s ability to demonstrate timely access. This is a national issue, as there is currently no agreed standard for healthcare assessment waiting times in police custody across Scotland. Inverness had a more structured approach, with referrals submitted electronically and triaged using a Red-Amber-Green (RAG) system. However, even with this system, the lack of a national standard or consistent data collection makes it difficult to evidence equitable and prompt access across all locations. There were effective processes in place to refer individuals to healthcare services In Wick, referrals were made verbally by custody staff during working hours, with out-of-hours referrals directed through Inverness. In Fort William, custody staff requested GP input via healthcare staff based in Inverness.

173. We were told detainees could also request to see healthcare staff at any point. Information regarding healthcare services was included in the booklet ‘Your rights when you are at the police station’. In Wick custody centre, posters were displayed at the charge bar detailing the healthcare that could be offered. Healthcare and police custody staff could access interpretation services to support patients with the vulnerability assessments and ongoing healthcare assessments. Language identification posters were visible in the charge bar area of the custody centre.

174. The Criminal Justice Services Division, in collaboration with healthcare partners, has developed guidance to clarify the roles and responsibilities of custody staff in maintaining patient confidentiality during healthcare interventions. Inspectors were informed that this guidance was being followed and monitored, with clinical examinations generally taking place in the treatment room. Patients could also be seen in their cell if their healthcare condition required this.

175. Across all custody centres, a risk assessment was carried out prior to patient consultations to determine the appropriate level of police staff presence. In Inverness and Wick, inspectors were told that the treatment room door is kept closed during consultations unless a safety concern was identified. However, in Fort William, inspectors were informed that despite a risk assessment being completed, the treatment room door is generally left open during consultations, due to the door being heavy and requiring effort to open, with a custody staff member positioned outside and out of hearing range. This allowed healthcare staff to summon help if required, without compromising confidentiality.

176. Custody and NHS staff used different computer systems that did not connect with each other, which made it harder to share information directly. Custody staff used the National Custody System (NCS), while NHS staff use Adastra.^[10] In Inverness and Wick, healthcare recommendations were emailed to a shared custody inbox and then added to the NCS. In Fort William, recommendations were written down and handed to custody staff, this information was then copied onto NCS and the paper copy disposed of appropriately. Healthcare and custody staff shared updates verbally to help communication.

177. NHS staff understood the process for recording injuries that may have been caused by the use of force. Where possible, any detainee request for specific healthcare staff to carry out health assessments would be facilitated.

178. All custody cells were wheelchair accessible, except those at Fort William. At Inverness custody centre, one cell was equipped with a raised bed to support detainees with mobility issues. Inspectors were informed that when individuals presented with complex physical, social, or care needs, a registered nurse would carry out a 'fitness to remain in custody' assessment. This would then be followed by a joint discussion between custody staff and healthcare staff to determine appropriate care. Emergency equipment, including oxygen, suction machines, and automated external defibrillators were available at Inverness and Wick custody centres, with evidence of regular weekly and monthly checks. In the event of a medical emergency, the Fort William custody centre relied on the Scottish Ambulance Service (SAS), who share the premises, as the facility itself is equipped only with a basic first aid box.

179. Systems were in place to manage emergency situations and minor injuries. In Inverness, healthcare staff had completed joint training and shadowing with SAS to better understand each other’s roles in delivering emergency care. In Wick, the CNM had engaged with the local emergency department to discuss the scope of care that could be provided in custody. This collaborative approach is considered good practice.

180. Training records showed that all nursing staff had completed Immediate Life Support training. The GPs with responsibility for Fort William custody centre were trained in Advanced Life Support.

Medicines management

181. NHS Highland had a pharmacist with responsibility for overseeing the governance of medicine management in the custody centres. They also provided clinical advice if required. The service had a range of Standard Operating Procedures (SOP) to support staff with the safe supply, storage, dispensing and safe destruction of medicines. Processes were also in place to order medications, including controlled drugs. Stock medications including controlled drugs were held in both Inverness and Wick custody centres, no stock medications were held at Fort William custody centre.

182. The pharmacist would visit the custody centre in Inverness to safely destroy out of date or no longer required controlled drugs. In Wick custody centre, controlled drugs were taken to Caithness General Hospital for destruction. We observed that controlled drug registers were well completed. In Wick, we were told and saw that custody staff were the second signatory when controlled drugs were being checked. No formal training was in place to support custody staff to carry out this role. Recommendation 10. A controlled drug license was in place for the custody centre in Inverness and we were told that the controlled drug license for Wick custody centre was in the process of being renewed.

183. The service had processes in place to ensure effective stock rotation and regular checking of expiry dates. During this inspection, drugs that were checked were found to be within their expiration dates. For drugs that were nearing their expiry date, a process was in place to return them to the pharmacies at Raigmore and Caithness General Hospitals, so that they could be used, therefore reducing waste. This is considered good practice.

184. Various methods were used to ensure robust medication reconciliation, including reviewing electronic records and consulting with the patient. This ensured that patients received their usual medication whilst detained, including any Opiate Substitution Therapy (OST). All registered nurses were non-medical prescribers and prescribed all medications. Prescriptions were recorded on Adastra, including prescriptions for controlled drugs. The healthcare team were aware of the recent communication from HIS with regards to prescribing via Adastra. In Inverness, a direction to administer was printed from Adastra and was signed by the prescriber. Administration of the medications was recorded on the direction to administer as well as on Adastra. All medications in Inverness custody centre were administered by nurses.

185. In Wick custody centre, healthcare staff dispensed medication into multi-compartment compliance aids to enable custody staff to administer medication; this did not include OST, which was dispensed by a nurse. Healthcare staff were able to describe the process for using compliance aids and a SOP was in place to support the use of them.

186. Patients in Fort William Custody centre who required medications were generally transferred to Inverness custody centre. However, if they were not transferred and the patient required medications, these were supplied and given by the GP. Multi-compartment compliance aids were available for those patients who did require medications for a longer period time whilst in Fort William custody centre. Compliance aids were filled by the visiting GP.

Substance use

187. In Inverness and Wick, nursing staff assessed patients who appeared to be under the influence of, or withdrawing from, alcohol or substances. They had access to the appropriate tools for monitoring withdrawals, carried out physical observations and prescribed detoxification medication where required. Similarly, in Fort William, GPs carried out assessments for detainees presenting with substance use concerns, ensuring appropriate clinical care and access to detoxification support where necessary.

188. In all custody centres, processes were in place for confirming, collecting and administering community prescriptions for patients within custody who were prescribed OST.

189. For patients appearing in court, OST was not routinely given prior to attending. However, detainees were consistently leaving for court early in the morning and communication systems were in place to ensure that OST was administered to patients upon release through community pharmacy services to ensure continuity of their OST.

190. Protocols and procedures were in place to ensure the continuation of daily prescribing requirements over weekends.

191. The Scottish Government’s Medication Assisted Treatment standards, which came into effect in April 2022, aim to ensure the consistent delivery of safe, accessible, and high-quality drug treatment across Scotland. Custody healthcare services have taken a proactive approach to implementing these standards. Detainees identified as being at risk of drug-related harm were offered a targeted intervention focused on substance use and harm reduction in Inverness and Wick. We consider this good practice. Detainees in Fort William were supported on an individual basis based on a clinical assessment. These interventions were available to both detainees already engaged with Drug and Alcohol Recovery Services (DARS) and those who are not. Detainees can also be referred to community DARS teams, Harm Reduction Services, and outreach teams for further support.

192. A range of harm reduction information and interventions were available and well utilised across all custody centres. Blood borne virus testing was offered to patients accessing healthcare in Inverness and Wick, but not routinely in Fort William, where FMEs signposted individuals to community services for follow-up. All healthcare professionals had access to Naloxone^[11] and were trained to administer it. In Wick, where there was not an onsite 24/7 healthcare provision, inspectors were told police sergeants and custody constables were trained and had access to Naloxone, therefore, there would always be someone available to deliver it when required. Take home Naloxone kits were also available to detainees.

193. There was a process in place for nicotine replacement therapy to be made available to detainees.

Mental health

194. Healthcare staff in custody settings were responsible for the initial triage and mental health screening of individuals in custody. While there were established processes for identifying and sharing risks between healthcare and custody staff, inspectors found that once a need for further assessment by secondary mental health services was identified, there was no clearly defined or consistently applied referral pathway, particularly for individuals requiring hospital admission.

195. Significant inconsistencies were observed in the effectiveness of care pathways for those needing specialist mental health input. These inconsistencies often resulted in delays in accessing timely and appropriate care.

196. For individuals requiring forensic mental health assessments, typically those involved with the criminal justice system, person-centred protocols were in place. These ensured that assessments were conducted by forensic mental health professionals within the custody setting, with access to high-security forensic inpatient beds when necessary.

197. In contrast, individuals experiencing acute mental health crises who did not require forensic services were intended to be admitted to general acute mental health units, which offer moderate security and focus on crisis stabilisation. However, the referral pathway to these services was not clearly understood by either inspectors or clinical staff within police custody. The process was often inconsistently applied, contributing to delays in accessing appropriate care.

198. Despite efforts by custody healthcare teams to work with secondary mental health care services, joint working was often ineffective, resulting in delays in assessment and hospital admission. A working group led by NHS Highland had been active for two years to improve protocols and pathways. However, inspectors expressed concern that progress remained limited, with patients continuing to face multiple assessments, long waiting times, and reluctance from secondary mental health care services to engage or provide timely support. Recommendation 11.

199. Protocols and processes were in place to ensure that custody was not used inappropriately as a place of safety, and that individuals were instead directed to suitable healthcare environments.

Pre-release pathways and referrals

200. When a detainee is transferred from a custody centre to court, a Person Escort Record (PER) form is completed. This form includes details about the patients’ medical condition and prescribed medications, which are sourced from the NCS.

201. There was clear evidence of signposting detainees to community support services, with custody staff demonstrating a strong awareness of the support available locally. A variety of leaflets and posters were displayed in custody centres, providing information on mental health, substance use, health and wellbeing, harm reduction, peer support, and family support services.

202. Guidance for healthcare staff on making onward referrals to community services was embedded within the SOP for both community mental health teams and substance use services.

203. Healthcare staff also had established communication processes with community pharmacies; mental health services and substance use services to ensure continuity of care following release from custody.

204. All custody centres had access to the Highland Interface Community Support Service. In Inverness, support workers visited the custody centre to raise awareness and encourage engagement with community services. Detainees held in Wick and Fort William could also be referred to the Highland Interface by custody staff.

[9] HAI-SCRIBE (Healthcare Associated Infection Systems for Controlling Risk in the Built Environment) is an online risk management tool designed to identify and assess for potential hazards in healthcare establishments. The goal of HAI-SCRIBE is to reduce infection hazards within the built healthcare environment.

[10] Adastra is an IT solution for use in police custody centres used by NHS staff and commissioned services. It is used as a clinical health recording system to support clinical care delivery for patients in police custody.

[11] Naloxone is an emergency antidote to overdoses as a result of heroin (or other opioid/opiate) use, which
reverses the suppression of the respiratory system.