Custody inspection report - Highland and Islands

Governance of healthcare

205. Police custody healthcare in the Western Isles is delivered by NHS Western Isles, which is governed through the Primary Care Department, led by the Family Health Services Manager.

206. This service supported police custody centres located in the Isle of Lewis and Harris, Uist, and Barra. In the Isle of Lewis and Harris, the service was nurse-led by Advanced Nurse Practitioners (ANPs), with individuals in custody attending the Stornoway Police Station. As part of this inspection, we visited only the Stornoway Police Station, due to the higher throughput of individuals in custody at this location. We did not visit custody centres in Uist and Barra. We were informed that in Uist and Barra, the service was managed by local 2C GP practices (GP practices run by the NHS Board). The model of having all services delivered by the NHS Board has strengthened oversight and promoted equitable training opportunities for all staff involved in custody assessments across the Western Isles. During evenings and weekends, the service in Uist and Barra was supported by the out-of-hours GP rota.

207. Over the past four years, NHS Western Isles has transitioned to a nurse-led ANP model for custody healthcare in the Isle of Lewis and Harris, supported by an established urgent care workforce. The service was delivered by ANPs, with local GPs offering on-call support as needed to maintain service coverage. The formation of a Custody Working Group, comprising of NHS Western Isles and Police Scotland, has led to the development of new care pathways, enhanced staff skills in managing individuals in custody, and strengthened overall service delivery. We considered this to be an example of good practice.

208. For specialist assessments, such as those related to mental health and substance use, the service has well-established and responsive pathways. Once an individual in custody is seen by an ANP or GP, they can be referred to the appropriate specialist service as needed. The service operated an integrated model that enabled joint assessments, particularly between mental health and substance use teams, ensuring timely, person-centred care. We considered this to be good practice.

209. Healthcare delivery was well managed, with a clear governance structure in place. Oversight was maintained through clinical and care governance processes, including regular governance and multi-agency meetings between NHS Western Isles and Police Scotland.

210. Training records reviewed during the inspection demonstrated compliance with both mandatory and role-specific training requirements; however, staff had not received training in the Istanbul Protocol.^[12] Recommendation 12. ANPs had completed the NHS Education for Scotland (NES) Rural Advanced Practitioner programme. We considered this to be good practice.

211. There was no visible information about how a detainee could make a complaint or give feedback on the healthcare service they received within the custody centre. Recommendation 13. At the time of our inspection, we found no evidence of any complaints being submitted within the past year.

212. The DATIX system, a widely used incident reporting and risk management tool in healthcare settings was being used by healthcare staff to record any incidents and adverse events. Incidents were reviewed and learning was shared within team meetings.

213. The treatment room in the Stornoway custody centre was visibly clean. 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 available in the treatment room. The management of blood or body fluid spillages was completed by an external company. Concerns with cleaning would be escalated through Police Scotland. Any repairs to the treatment room were reported through Police Scotland.

214. Patient 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. The only Personal Protective Equipment (PPE) available were gloves, however, these were not stored appropriately; close to point of use and in a clean, dry area to prevent contamination Recommendation 14.

215. Sharps bins used for disposing of used sharps were available but not signed and dated. Recommendation 15.

216. Although a clinical waste bin was available, the bag was not colour coded and clearly labelled. Recommendation 16. Clinical waste was stored securely and was disposed of in line with guidance.

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

218. During the inspection, we observed that a ceiling tile had been removed in the treatment room due to water ingress because of heavy rainfall. NHS Western Isles had not been informed of the damage. We raised this with senior healthcare staff, including the Associate Medical Director, the Family Health Service Manager and the Lead for Urgent and Unscheduled care. They immediately arranged a health and safety visit to the custody centre. Following the visit, the examination couch was moved to another area within the treatment room away from the missing ceiling tile and a visit from the Health Protection Team was arranged. Once the Health Protection Team’s completed reports have been received, a contingency plan will be developed to reduce the potential IPC and Health and Safety risk to both patients and staff. Recommendation 17.

219. There was no programme of local IPC audits in place. Recommendation 18. Staff spoken with described that NHS Western Isle’s Health Protection Team supported community areas, including police custody. The National Infection Prevention and Control Manual (NIPCM) was available on the staff shared drive. Training records showed all nursing staff had completed IPC training.

Access to healthcare

220. 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.

221. Although custody staff reported satisfaction with healthcare response times, the absence of a system to record actual waiting times, limits 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. Custody staff refer patients to the on-call clinician. A list of ANPs and GPs, including contact details, is shared with all custody centres a month in advance. All calls are triaged, and depending on the patient’s needs, the healthcare professional either attends the custody centre or advises hospital attendance.

222. Detainees could also request to see healthcare staff at any point. Healthcare staff told us these requests would always be facilitated. 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 assessments and ongoing healthcare assessments. Language identification posters were visible in the charge bar area of the custody centre.

223. 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 for detainees 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 treatment room. Inspectors were told that the door to the treatment room would be closed during patient consultations, unless custody staff had highlighted this as a safety risk.

224. 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.[13] Healthcare recommendations were given verbally to custody staff. A more robust system should be introduced to reduce the risk of healthcare information being missed or recorded incorrectly. Recommendation 19. 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.

225. There were no wheelchair accessible cells in the custody centre. An automated external defibrillator was available in the custody centre and inspectors were told this was checked by custody staff on a regular basis. Systems and processes were in place for the management of emergency situations and minor injuries. Training records showed all nursing staff had completed Immediate Life Support training.

Medicines management

226. NHS Western Isles had a pharmacist, a pharmacy technician and a pharmacy assistant overseeing medicine management within the Stornoway custody centre. No stock medications were held in Uist and Barra. The service had Standard Operating Procedures (SOP) to support staff in the safe supply of medicine and to manage the drug stock levels for Stornoway police custody centre. No controlled drugs were held in the custody centres.

227. The medication cupboard keys were securely kept with the urgent and unscheduled care team at the local hospital. There was an established process evident to ensure stock levels are monitored and expiry dates checked on a bi-monthly basis.

228. 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. There were processes in place with the Substance Use Services to ensure that detainees would be assessed for withdrawals, and where a patient was noted to be established on Opiate Substitution Therapy (OST), their treatment was continued during their period in custody. Medications were prescribed by the ANPs, who were non-medical prescribers and the GP, and recorded on Adastra. We were told only prescribers had access to the function within Adastra to support the prescribing of medicines.

229. The supply of medication, if not available from the custody centre stock cupboard, was collected from the local hospital or where possible, the patient’s home by custody officers.

230. We were told by the Unscheduled Care Team lead and lead pharmacist that medicines were dispensed through the use of multi-compartment compliance aids, which were prepared by the GP or ANP, to enable custody staff to administer medication. However, custody staff told us that they may be advised by the healthcare professional, over the phone, to administer patient’s own over-the-counter medication. There was evidence that a SOP for the administration of medicines was in development. Recommendation 20.

Substance use

231. ANPs 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, carrying out physical observations and prescribed detoxification medication where required.

232. The Substance Use Team based in Stornoway forms part of the healthcare service provided within police custody. They attend the custody centre to assess individuals and determine any further interventions required. Their responsiveness to requests for assessment, treatment, or support for detainees with substance use needs was viewed positively by custody staff. This timely involvement helped to ensure individuals receive appropriate care without delay, reduces the risk of withdrawal-related complications, and supports continuity of treatment during their time in custody.

233. In the Western Isles, the majority of individuals receiving OST were prescribed Buvidal, a long-acting injectable. This facilitated continuity of treatment for those who enter police custody. Naloxone^[14] was available in custody areas for emergency use, and take-home kits with training could also be provided to detainees.

234. We did not see any visible evidence of health promotion posters or self-help information within the custody areas. This was being addressed by staff following discussion.

Mental health

235. In custody settings, initial triage and mental health screening was carried out by the on-duty ANP or GP. If a full mental health assessment was needed, a Registered Mental Health Nurse (RMN) from the Adult Mental Health service attended the custody centre.

236. The Adult Mental Health service in NHS Western Isles operated as a coordinated network, including mental health, addiction, learning disability, and older adult teams, as well as consultant psychiatrists and inpatient services. This integrated model enabled joint assessments, particularly between mental health and addiction services, ensuring timely, person-centred care.

237. The Mental Health Team provided 24-hour on-call cover, supporting prompt access to care. Clear procedures and protocols were in place to ensure effective communication of risk between healthcare and custody staff. This integrated and responsive approach was considered good practice. Mental health assessments and risk evaluations were carried out using standardised tools. A structured communication form is completed when an assessment is required before court. While the RMNs were not yet fully trained in the electronic records system used in custody, training was planned. Standardised assessments and risk assessments would therefore be recorded on the MORSE clinical IT system specific to mental health services.

238. Both mental health staff and custody staff we spoke to confirmed that Stornoway’s police custody centre was not used as a place of safety under section 297 of the Mental Health Care and Treatment, Scotland Act 2003. Police officers would take the patient requiring urgent mental health care to Western Isles Hospital, which was the designated place of safety.

Pre-release pathways and referrals

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

240. There was clear evidence of signposting detainees to community support services, including referral to health and third sector agencies. SOPs to support referral to mental health services and Substance Use Team were in place. Referrals could be made by both healthcare staff and custody staff.

241. Within the custody centre, there were patient information leaflets available which were printed as needed. Leaflets included details for health contacts, third sector agencies, recovery and harm reduction services and self-help support via mobile phone applications apps. For example, STOPP-decider skills, Calm Harm, Clear fear and Silver Cloud CBT. Healthcare and custody staff showed awareness of the impact of release from custody on individuals, their families and communities, and made appropriate referrals to support services to ensure continuity of care.

[12] OHCHR, Istanbul Protocol, 29 June 2022.

[13] 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.

[14] 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.