Custody inspection report - Highland and Islands

Governance of healthcare

275. Our overall inspection finding for NHS Orkney highlighted the clear need to strengthen governance and formalise processes for healthcare provision within police custody. While current arrangements reflect low case volumes, the reliance on informal systems poses risks to patient safety, service consistency, and staff confidence. The absence of clear protocols, tailored training, and robust data capture limits accountability and may lead to fragmented care. In light of these concerns, we wrote to NHS Orkney following our inspection, asking them to begin making improvements immediately rather than waiting for the final report to be published. Addressing these gaps should be a priority to ensure safe, lawful, and coordinated healthcare delivery in custody settings.

276. Healthcare provision within police custody in Orkney was integrated into NHS Orkney’s existing Emergency Department and out-of-hours (OOH) GP teams rather than through a dedicated service. Care was provided through a dual-service model. Emergency Department staff cover weekday hours, while OOH GPs were responsible for covering evenings and weekends. Referral pathways for detainees requiring healthcare follow standard emergency department or OOH procedures, as there were no custody specific protocols. Police officers escort patients directly to Balfour Hospital when necessary. Although OOH GPs were expected to attend the custody centre, this did not always happen consistently, due to OOH staff requesting police officers to bring the patient to the OOH at Balfour Hospital. The custody centre was staffed only when needed, with no permanent police personnel assigned to it.

277. Training for staff that may be required to provide care in custody settings was managed within their respective core teams, with no separate training log or mandatory training programme specific to custody healthcare in place. Similarly, induction processes followed the standard NHS Orkney protocols for the Emergency Department and OOH services, with no tailored induction for the custody environment. While this approach may be proportionate, given the low frequency of custody related healthcare encounters, it may present challenges for staff unfamiliar with the unique context and requirements of the custody setting. To ensure safe, consistent, and contextually appropriate care, there remained a need for bespoke training and induction that addressed the specific clinical, legal, and operational considerations of working within police custody.
Recommendation 32.

278. No complaints or adverse events relating to custody healthcare have been reported in the past year. Any future concerns would be managed through the formal complaints process and recorded in the DATIX system, a widely used incident reporting and risk management tool in healthcare settings. Oversight was provided from the Head of Primary Care and the joint Integration Joint Board (IJB) Clinical Care Governance Group. However, no information on how to provide feedback or make a complaint was visible within the custody centre, which may limit the patients’ ability to raise concerns. This was an area that could be improved to support transparency and service user engagement. Recommendation 33.

279. At a senior level, the Police Area Commander for Orkney, currently liaises with healthcare services through broader multi-agency partnerships. There were no formal multi-agency meetings focused specifically on custody healthcare, although the topic was included as a standing item in the monthly OOH GP meeting. Data on healthcare access in custody was limited. OOH GPs were trained in the use of Adastra,^[17] however, not all GPs consistently used the system. Some clinical interactions were recorded in paper notes as part of routine Emergency Department documentation, but there was no centralised or systematic data capture specific to custody healthcare. This could lead to gaps in healthcare records.

280. Fewer than 100 people require healthcare while in custody in Orkney each year. Due to this low volume and limited healthcare data, NHS Orkney should consider using Police Scotland’s detention records to better understand demand, including detention duration and outcomes.

281. Improved data collection would support service planning, training, and targeted interventions. Even at low volumes, structured recording of healthcare interactions would enhance understanding of this population’s needs and strengthen clinical governance and strategic oversight. Recommendation 34.

282. Through discussions with healthcare and police custody staff, it became evident that a reliance on informal arrangements had contributed to a disconnect between services. The absence of clear, formalised processes had created uncertainty for police custody staff, who reported that the lack of guidance can make it difficult to manage detainee care effectively. While NHS Orkney has cited low activity levels as a rationale for not implementing formal procedures, custody and healthcare staff feedback suggests that even basic guidance would enhance service delivery. Introducing clear protocols would promote consistency, improve inter-agency communication, and strengthen accountability. Structured guidance would also ensure that all staff, regardless of their role or how frequently they are involved, are equipped to provide safe, coordinated care within the custody setting. Recommendation 35.

283. NHS Orkney acknowledged the need for improvement and had planned support, including a site visit from NHS Highland clinical staff, as a key partner in the North of Scotland Forensics and Custody Healthcare Alliance (TAY initiative). NHS Highland has played a leading role in sharing knowledge across the region. Their influence was evident during inspections of other islands custody centres, where their support had clearly strengthened local practice.

284. The medical room was visibly clean and well maintained. We were told OOH GPs were responsible for cleaning the surfaces and care equipment in the treatment room. Cleaning of the floors was the responsibility of the custody centre cleaner. The management of all blood or body fluid spillages, including those in the medical room was completed by an external company. The standard of environmental cleaning was described as good. Concerns with the standard of floor cleaning would be escalated through Police Scotland.

285. Any repairs or works required to be carried out in the medical room were reported through Police Scotland.

286. Care equipment was visibly clean and in good condition. Hand hygiene facilities were available. Although Personal Protective Equipment (PPE) was available it was not stored appropriately; close to point of use and in a clean, dry area to prevent contamination. Recommendation 36.

287. Sharps bins, which were used for disposing of used sharps, were not signed or dated, and we were unable to ascertain who managed them. Recommendation 37. Clinical waste was stored securely in a locked area and was disposed of in line with guidance.

288. No linen was used by healthcare staff in the custody centre.

289. We were informed that the most recent Infection Prevention and Control (IPC) audit was completed in November 2024, and a summary report was subsequently shared with all relevant stakeholders.

Access to healthcare

290. 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 being made to healthcare staff.

291. There is currently no nationally agreed standard for healthcare assessment waiting times for people detained in police custody centres across Scotland. Patients referred during working hours were escorted by custody staff to the Emergency Department at Balfour Hospital, while those referred out of hours were seen through the OOH GP Service. However, the absence of a system to record actual waiting times limited the service’s ability to demonstrate timely access to care, highlighting a national issue in the consistency and transparency of healthcare provision in custody settings.

292. Detainees could also request to see healthcare staff at any point. Information regarding healthcare was included in the booklet ‘Your rights when you are at the police station.’ Healthcare and police custody staff could access interpretation services to support patients with the vulnerability assessment and ongoing healthcare assessments. Language identification posters were visible in the charge bar area of the custody centre.

293. The Criminal Justice Service Division, in collaboration with healthcare partners, had produced guidance and clarity for custody staff of their roles and responsibilities of maintaining patient confidentiality for patients when undergoing intervention and treatment by the healthcare team. Inspectors were told that this was being followed and monitored, with clinical examinations generally carried out in the Balfour Hospital’s Emergency Department.

294. The separate electronic systems used by custody staff and NHS staff to record custody data were unable to connect with each other to share information. Custody staff use the National Custody System (NCS) to record information relevant to detainees, whereas NHS staff use a combination of Adastra (OOH GP) and paper records (Emergency Department), depending on time and day. Healthcare recommendations were given verbally to the police. A more robust system should be introduced to reduce the risk of healthcare information being missed or recorded incorrectly. Recommendation 38. NHS staff were aware of the process for identification and documentation of injuries allegedly sustained because of force. Where possible, any detainee request for specific healthcare staff to carry out health assessments would be facilitated.

295. Cells were not wheelchair accessible, although one cell did have a raised bed to support those detainees with mobility issues.

296. An automated external defibrillator was available at the entrance to the police station, and we were told that the custody staff took responsibility for checking it regularly. When the OOH GPs attended the custody centre, we were told they would bring their own emergency equipment and medication.

Medicines management

297. We were told that there was a pharmacist in NHS Orkney who had responsibility for supporting the governance of medicines management in the custody centre. The service had no policies or SOP in place to support staff with the supply, storage, dispensing and the safe destruction of medicines for the police custody centre. Recommendation 39.

298. No stock medications or controlled drugs were held at Orkney custody centre. Instead, controlled drugs were held in a dedicated controlled drug cupboard in the Emergency Department of Balfour Hospital.

299. Medications were prescribed by either healthcare professionals in the Emergency Department at Balfour Hospital or the OOH GPs. Various methods were used to ensure robust medication reconciliation, including checking electronic records.

300. It was unclear from speaking with custody and healthcare staff what the process was for managing patients’ Opiate Substitution Therapy (OST). Single doses obtained were administered by the healthcare professional or OOH GP when received. Occasionally, two doses of methadone were obtained for a patient, the first was typically administered immediately, while the second (intended for the following day) must be stored and recorded in accordance with controlled drug storage requirements. However, staff were not always clear on how this should be managed in practice.

301. Due to the Emergency Department staff being unable to access Adastra and OOH GPs recording prescriptions on Adastra, there was an increase in the likelihood of errors in communication and crucial information being missed.

302. We were told that OOH GP occasionally placed medication into multi-compartment compliance aids to enable custody staff to administer medication. This did not include OST which was administered by a nurse. During the inspection, we saw no evidence of a Standard Operating Procedures (SOP) to support this. It was noted that there was no training for GEOAmey staff in the use of compliance aids to support medicines administration. Recommendation 40.

Substance use

303. In Orkney, patients who require support for substance use are referred to the Emergency Department or the OOH GP service for assessment.

304. The service is not fully aligned to Scotland’s Medication Assisted Treatment (MAT) Standards, which require timely access to evidence-based treatment for drug use, including Opioid Substitution Therapy (OST). Staff reported that the number of patients receiving OST in custody was extremely low, with no recent cases recorded. As a result, there were no formal pathways for continuing OST in custody, and staff were unable to describe how access would be managed. However, they could clearly outline referral pathways to community services for detainees with substance use issues.

305. For patients experiencing substance withdrawal, the Emergency Department and OOH GP staff respond based on clinical presentation, using withdrawal assessment tools and prescribing medication if clinically indicated. These medications are labelled and handed to custody staff for administration, with further assessment requested if concerns arise.

306. Staff also told us that medications may be brought from home or collected from a pharmacy, verified and prescribed for daily use. Following assessment, the Emergency Department or GP staff communicated outcomes to custody staff, who then record the information on the NCS system; this would include details on the level of observations.

307. Inspectors were informed that custody staff had access to Naloxone,^[18] a life-saving medication that rapidly reverses the effects of opioid overdose. Naloxone was also available through OOH services and the Emergency Department, ensuring individuals in police custody could receive timely emergency treatment in the event of an opioid-related incident.

308. While substance use cases in custody were rare, having a SOP in place would help ensure timely and consistent care when such cases do occur.

Mental health

309. People identified as having a mental health condition, including a pre-existing diagnosis, were referred by police staff either to the Emergency Department during standard working hours, or to the OOH GP service at other times. Once a mental health condition had been identified and the initial health screening and risk assessment were completed, contact was made with the local on-call community psychiatric nurse to request a mental health assessment. As there were no psychiatric inpatient beds in Orkney, detainees requiring admission were held in a designated room within the Emergency Department while arrangements were made for transfer to a mainland facility.

310. Psychiatric consultations were conducted remotely via the Near Me video platform, as psychiatrists were not based in Orkney. If follow-up care was required upon release from custody, efforts were made to arrange onward referrals during the patients’ time in custody to ensure support was in place prior to liberation. While staff were able to describe the referral pathway, there were currently no formal SOPs in place. The police custody centre is not used as a place of safety under Section 297 of the Mental Health (Care and Treatment) (Scotland) Act 2003; instead, a dedicated room within Balfour Hospital was used for this purpose, with established pathways for assessment once patients were detained by the police. Information would be sent to the patient’s GP via an Emergency Department discharge summary

Pre-release pathways and referrals

311. On release from police custody in Orkney, people can be referred to a range of community-based supports to help address mental health and substance use needs. Referrals can be made directly by the OOH, GP or Emergency Department staff to local mental health and substance use teams. In addition, people can access services provided by the Orkney BLIDE Trust, which offers a range of support options tailored to people’s needs. These include one-to-one support, drop-in services, therapeutic activities, housing support, counselling, befriending and the Money Matters Project. These services provide a holistic approach to recovery and reintegration, supporting people in building stability and wellbeing following their time in custody.

[17] 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.

[18] 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.