Custody inspection report - Highland and Islands

Governance of healthcare

242. Prior to 2023, custody healthcare services relied heavily on locum GPs, with only one permanent GP in place. This model was considered unsustainable due to its overdependence on temporary staff, which posed risks to service continuity and quality. In response, a pilot programme was launched to introduce Advanced Nurse Practitioners (ANPs) into the service. This initiative was supported by targeted training and off-island placements, aimed at building the necessary skills and capacity within a more stable and resilient workforce. The healthcare service is now delivered by a team of ANPs and local substantive GPs on an on-call basis in hours and was fully integrated into the out-of-hours (OOH) service. Leadership was provided by senior nursing and primary care staff, with regular team meetings supporting continuous improvement.

243. Managed directly by the NHS Board, the service operated within a clear governance structure. No complaints or adverse events had been reported in the past 12 months. Any complaints or issues received would be managed through NHS Shetland’s formal complaints process and recorded in the Datix system, a widely used incident reporting and risk management tool in healthcare settings. Complaints would be reviewed by the custody healthcare team and the Clinical and Professional Oversight Group to ensure appropriate action, accountability, and continuous quality improvement. However, no information on how to provide feedback or make a complaint was observed as being available within the custody centre, which may limit the patient’s ability to raise concerns or suggestions. This was an area that could be strengthened to support transparency and service user engagement. Recommendation 21.

244. New staff received comprehensive induction materials covering both NHS Shetland and custody-specific guidance. Multi-agency meetings with Police Scotland and community services had not taken place for some time, but plans were in place to restart them, with both organisations recognising this as a key gap that needed support to strengthen collaboration. All staff benefitted from peer supervision to reflect on complex cases and had annual appraisals. Structured meetings were held to discuss updates, concerns, and medication management.

245. Clear referral pathways were in place for access to A&E, mental health, primary care, and substance use services, including emergency 999 referrals. A Standard Operating Procedures (SOP) for medicines management was being developed, alongside local SOPs for custody services to enhance consistency and safety as the service develops. Despite a lack of SOPs, healthcare and custody staff we spoke with were able to describe clearly and consistently how healthcare was delivered. Data collection had been delayed due to the late implementation of Adastra,^[15] this system will support future audit and reporting. Local audits were a planned area for improvement.

246. Notably, staff showed a strong awareness of the local population’s needs. NHS Shetland aimed to shift custody healthcare from reactive to proactive, addressing complex needs more holistically. Recognising the limits of police referrals, plans included expanding access to all detainees, increasing ANP outreach for those facing barriers, and strengthening post-release support, marking a positive step towards greater equity and improved outcomes.

247. The treatment room was visibly clean and tidy. Healthcare staff told us they were responsible for cleaning the surfaces in the treatment room. Cleaning of the floors was the responsibility of the custody centre cleaner. An appropriate chlorine-based cleaning product was not seen to be available. The management of all blood or body fluid spillages, including those in the treatment room, was completed by an external company. Healthcare staff described the standard of environmental cleaning as satisfactory. Concerns with cleaning would be escalated through Police Scotland.

248. We noted some damage to the walls and the flooring in the treatment room, which would not allow for effective decontamination. Recommendation 22. Any repairs or works required to be carried out in the treatment room were reported through Police Scotland or NHS Shetland estates and facilities department.

249. Care equipment was visibly clean and in good condition. Healthcare staff told us that it was cleaned between patient use. Hand hygiene facilities were available; however, hand soap, alcohol-based hand rub and hand towels were not in wall mounted dispensers. Recommendation 23. Personal Protective Equipment (PPE) was available and appropriately stored.

250. Sharps bins, which were used to dispose of used sharps, had their temporary closures in place, but were not correctly labelled. They were stored on the floor under the treatment couch. Recommendation 24. Clinical waste was disposed of in line with guidance.

251. No linen was used by healthcare staff in the custody centres. There was no programme of local IPC audits being carried out to provide assurance. Recommendation 25. The National Infection Prevention and Control Manual (NIPCM) was available on the staff intranet, and we were told that the NHS Shetland IPC team were easily contactable for advice. Training records showed that all nursing staff had completed IPC training.

Access to healthcare

252. 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 given by the detainee when completing the vulnerability questionnaire may result in a referral being made to healthcare staff.

253. 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 was not unique to Shetland; there is currently no nationally agreed standard for healthcare assessment waiting times in police custody across Scotland. In Lerwick, referrals were made via phone to Gilbert Bain Hospital reception, who then contacted the on-call or OOH healthcare staff. These staff triage referrals based on clinical need and wider service demands, but without recorded data, it was difficult to evidence equitable and prompt access for all detainees.

254. Detainees could also request to see healthcare staff at any point. Healthcare staff and custody staff told us these requests would always be facilitated. Information regarding healthcare services 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.

255. The Criminal Justice Service Division, in collaboration with healthcare partners, had produced guidance and clarity for custody staff on their role and responsibilities for maintaining patient confidentiality when undergoing intervention and treatment by the healthcare team. Most of the healthcare was delivered in a patients’ cell due to the limited size of the treatment room at Lerwick custody centre. According to staff, the cell door was generally left open, with custody personnel situated outside and out of hearing range, allowing healthcare staff to summon help if required without compromising confidentiality.

256. 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 Adastra. We were told that healthcare recommendations, including those relating to medications were recorded directly onto the NCS system by healthcare staff. While this approach reduces the risk of healthcare information being missed or wrongly transcribed, NHS Shetland and Police Scotland should ensure that appropriate governance systems are in place to support this approach. Recommendation 26. Additionally, healthcare staff and police custody staff were able to provide verbal updates on the patients. Healthcare 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.

257. Cells were not wheelchair accessible and none had raised beds that could be used to support those detainees with mobility issues. Inspectors were told if patients had complex physical, social or care needs, a fitness to remain in custody assessment would be completed by the ANP followed by a joint discussion between custody staff and healthcare staff. This is considered good practice.

258. Systems and processes were in place for the management of emergency situations and minor injuries. An automated external defibrillator and airway management equipment was available in the custody centre and the GPs and ANPs attending the custody centre would also bring their own emergency equipment. OOH vehicles also used contained oxygen if required. Emergency medications were also available and in date. We were told that OOH equipment was checked as part of the OOH healthcare staff duties. However, records of these checks of the equipment in Lerwick custody centre being checked were not kept. Recommendation 27.

259. Training records showed that all nursing staff had completed appropriate emergency care training.

Medicines management

260. NHS Shetland had a pharmacist responsible for overseeing the governance of medicine management in the custody centre. They also provided clinical advice relating to medications if required.

261. Small amounts of stock medications were stored on site. Paracetamol, which custody staff needed to access when it was required by patients, was stored in the same cupboard as the stock medication. As custody staff had access to the drug keys and cupboard, they could also access prescription only stock medication. Recommendation 28. It was the responsibility of the pharmacy team to ensure the medication cupboard was topped up. It was noted that this should be done weekly, but the inspection team was advised that this had not been consistent due to staffing issues within the pharmacy. During this inspection, the drugs checked were found to be within their expiration dates. Controlled drugs were not held at Lerwick custody centre. Instead, controlled drugs were held in a dedicated controlled drugs cupboard in the Emergency Department of the local hospital. Custody healthcare staff and pharmacy staff were responsible for checking and managing the stock of these controlled drugs. When controlled drugs were required in the custody centre, they were transported from the Emergency Department to the custody centre by healthcare staff in their own or in OOH cars. We were told that medications were not securely stored in a lockable container during transfer. Recommendation 29.

262. 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 ANPs were non-medical prescribers and along with GPs prescribed all medications; prescriptions were recorded on Adastra. This included prescriptions for controlled drugs. The healthcare team at Lerwick custody centre was aware of the recent communication from HIS with regards to prescribing via Adastra. They were able to confirm that only prescribers have access to Adastra, managing the risk of individuals who were not prescribers making prescribing decisions for patients in custody.

263. In Lerwick custody centre, healthcare staff dispensed medication into multi-compartment compliance aids to enable custody staff or GEOAmey staff to administer medication. This did not include OST, which was dispensed by an ANP. Healthcare staff were able to describe the process for using compliance aids. It was noted that there was no training for GEOAmey staff in the use of compliance aids to support medicines administration. Recommendation 30. During the inspection, we saw evidence of a SOP to support this, although it was noted that this expired in December 2024. Recommendation 31.

Substance use

264. People entering custody with substance use issues have access to immediate clinical support through the on-call GP or ANP. These clinicians conduct assessments, including detailed histories and use appropriate withdrawal assessment tools to identify and manage withdrawal symptoms. Based on clinical findings, a tailored treatment plan is implemented, which may include the administration of OST if this was already prescribed to the individual. OST can also be administered prior to court appearances when clinically indicated. This approach ensured that acute needs were addressed promptly upon entry into custody.

265. However, for longer-term care and a broader range of interventions, support was primarily provided through established community services. There were well-established referral pathways to the Shetland Substance Recovery Service, particularly for patients already engaged in Medication Assisted Treatment (MAT). These pathways support continuity of care and reflect a collaborative approach between custody-based healthcare and community providers, aligning with the service’s commitment to proactive, person-centred care planning.

266. Nicotine replacement therapy was offered to all detainees who required it.

267. We were informed that custody staff had access to Naloxone,^[16] a life-saving medication that rapidly reverses the effects of opioid overdose. Naloxone was also available through the OOH service ensuring individuals in police custody could receive timely emergency treatment in the event of an opioid-related incident.

Mental health

268. Healthcare support for patients in custody is initially provided by the on-call clinician, who is either an ANP or a GP and conducts the initial triage and mental health screening. Established procedures ensure that any identified risks are effectively communicated between healthcare and custody staff, supporting a coordinated approach to care.

269. Where the initial assessment indicated a need for more specialised mental health input, the duty community psychiatric nurse or psychiatrist was contacted to attend the custody centre and carry out a comprehensive assessment. If clinically appropriate, arrangements were made for admission to an inpatient mental health facility to ensure the individual received the necessary level of care.

270. As part of the release planning process, referrals to community-based services such as the Community Mental Health Team or the Shetland Substance Recovery Service were arranged where appropriate. In some cases, these referrals were initiated prior to release by healthcare staff to ensure continuity of care and support following discharge from custody.

271. We were told that the police custody centre was not used as a place of safety under the Mental Health (Care and Treatment) (Scotland) Act 2003. When officers encounter people who appear to be experiencing significant mental health distress and may require urgent care or support, they direct them to the designated place of safety at Gilbert Bain Hospital, in accordance with Section 297 of the Act. This approach ensures that patients receive timely and appropriate mental health assessment in a clinical environment rather than in a custodial setting.

272. Where applicable, community care records can be accessed if the individual is a resident of Shetland.

Pre-release pathways and referrals

273. 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 detainee’s medical condition and prescribed medications, which are sourced from the National Custody System (NCS).

274. Referral pathways for people leaving custody in Shetland were relatively well-developed, with direct referral options to local mental health and substance use teams. Community-based supports, such as the Shetland Recovery Hub & Community Network play a central role in post-release care. The Hub offers a holistic drop-in service that includes one-to-one support for people and families affected by alcohol or substance use. It provided access to a broad range of services under one roof, including financial and housing advice, digital and oral health support, Naloxone distribution, sterile injecting equipment, and weekly housing support. While there is currently no access to harm reduction supplies at the point of liberation, the service recognised this as a gap and sees addressing it as an opportunity to further enhance its support. This aligns with its vision to expand and deliver a more holistic, proactive approach to care, particularly during the critical transition from custody to community services.

[15] 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.

[16] 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.