Billy Paul Thomas Salton

Date of report	6 Jan 2014
Reference	2014-0002
Deceased	Billy Paul Thomas Salton
Coroner	Joanne Kearsley
Coroner area	Manchester South
Category	State Custody related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Chief Constable, Greater Manchester Police

1 | CORONER
| am Joanne Kearsley, Area Coroner for the Coroner Area of Manchester South.
2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.

“a

INVESTIGATION and INQUEST

On the 17" July 2012 | commenced an investigation into the death of Billy Paul
Thomas Salton, date of birth 04.01.1993. The investigation concluded at the end
of the inquest on 27" November 2013. The conclusion of the Inquest was that
the deceased died as a result of 1a) Hypoxic Ischaemic Encephalopathy 1b)
Cardiac Arrest 1c) Epilepsy, and a shart forrn conclusion of natural causes was |
recorded.

a

oh
CIRCUMSTANCES OF THE DEATH

The deceased was an epileptic whose compliance with his medication was, at
times, variable.

On the 5™ July 2012 he presented at Cheadle Police Station where he was
detained by Greater Manchester Police. He was noted by the Custody Staff to
be an epileptic who was not in receipt of any of his medication. Due to his
medical condition he was placed in a CCTV cell although there were no
instructions given to any officers as to how long or when the CCTV should be
monitored. :

Medica! advice was therefore sought from MEDACS. The deceased was visited
and examined by He was found to be fit to be detained; no
medication was prescribed for him at this stage. In his tions
indicated that he did ask Mr Salton about when his last fit was, the time before

that and when he was last in hospital. However he did not record any answers
given on the documentation. He was not in a position to be able to verify Mr

Salton’s prescription with his GP to the time and therefore he did not issue any
medication. He did not enquire as to how long Billy was going to be in custody
and assumed he was being placed before the court in the morning. He did not
therefore set a time for enquiries to be made in the morning with the
deceased’s GP about his medication.

Shortly after this examination Billy had a seizure in his cell; this was un-
witnessed at the time but has been seen subsequently on the CCTV footage.

On the morning of the 5‘" July the deceased indicated to the police and his legal
representative that he did not feel well and thought he might have had an
epileptic seizure and that he needed his medication. The police therefore
requested a further medical assessment. The deceased was visited on this
occasion by Nurse from Medacs. Nurse Ould not access the
handwritten contemporaneous notes made previously by DO ZZ This
assessment could not be completed _as the deceased ceased co-operating and
left the medical room when Nursdiiilll informed him he could not prescribe
medication.

Nurse HB completed the detained person’s medical form indicating that
the assessment had been completed and the deceased was fit to be detained,
interviewed and transferred. No further enquiries were made to try and verif

his prescribed medication. On handwritten notes made by Nurse

nothing was noted on the detained person’s medical records that the police
should try and obtain medication from Mr Salton’s home address. None of the
police officers on duty recalled Nurse passing this information on to
them.

His GP details were subsequently obtained by his tegal representatives who had
re-attended at the police station for the interview. The police verified and
obtained his medication. A third medical request was then made for the
medication to be administered.

Nurse IE attended in order to administer the medication. She did not
read through all the entries made on the previous Detained Persons Medical
Forms. As she was asked to attend sinply to administer medication she did not
carry out an assessment of Mr Salton. However she then completed a Detained
Persons Medical Form indicating that the deceased was fit to be detained,
interviewed and transferred. The deceased was then prescribed his first dose of
medication.

Mr Salton remained in custody overnight. His second dose of prescribed
medications was administered at approximately 6pm. At approximately 8.40am
the deceased had a second un-witnessed seizure in his cell.

Staff from GEO AMEY attended at the police station to transfer Mr Salton to
Court. They had sight of his Prisoner Escort Form (PER) and the Detained
Persons Medical Forms (Form 708) which accompanied him. It was noted by
the GEO AMEY staff that these indicated that Billy was fit to be detained,
interviewed and transferred. It was also noted that he was an epileptic. The |
forms were not read thoroughly and in her evidence the escorting officer
indicated that she was unsure that Billy might have had a seizure whilst in
custody, what his level of observations might have been or that he had been
placed in a CCTV cell. oe

i

At Stockport Magistrates’ Court there was a delay in being able to deal with Billy
in Court. Billy was seen by his legal representatives and at that stage Billy
indicated that he felt OK. He was in a cell waiting to be called to Court. The last
recorded cell check was at 11.56am, (recorded as 12:05 on the computer print
out). Approximately 15 minutes later Billy was found collapsed in the cell. CPR
was performed and he was taken to Stepping Hill Hospital where he died.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless action
is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

1. During the course of the evidence | heard that Mr Salton had remained
in custody overnight and was not progressed as quickly as he could have
been whilst in custody as there was no-one available to interview him.
This is as a result of GMP policy on how people are progressed through
custody. The Prisoner Processing Unit is not staffed overnight which
leads to people being in custody longer than they should be and bringing
GMP “up against the requirements of the Police and Criminal Evidence
Act.” GMP cannot indicate how many people may have been detained
in custody longer than they should have been under their new policy.

2. There was a lack of understanding amongst the custody staff and staff
from other agencies as to the level of observations Mr Salton was on and
why he was on those observations. It is important that everyone who |
has care of someone in custody understands what the observations have
been, what they should be, when they are to be carried out, whether
rousing is required and why the observaticns are set as they are — i.e.
what the medical condition/ concern is.

3. When the deceased is visited and checked all such visits should be '
accurately recorded on the custody record.

4. Risk assessments carried out whilst in police custody should be recorded
when they are done. If there are no changes to a risk assessment then
this should be recorded and any rationale noted.

5. Handovers between Custody Sergeants were ineffective and there was
no handover between the Civilian Detention Staff. important
information was missed or iost in translation. Proper handovers should
take place as to a detained person’s condition, risk assessment, any

medical condition, level of visits and other important matters.

6. The Prisoner Escort Form was incorrectly completed. The final Custody
Sergeant should ensure that the transferring documentation is accurate.

7. There were no specific instructions to monitor Mr Salton whilst he was
in the CCTV cell. The CCTV screen is situated furthest away from the
desk where someone in the back office is more likely to be seated (next
to the security controls) meaning that there is less likelihood of them
“glancing” at the CCTV screen.

ACTION SHOULD BE TAKEN

| believe that this level of information should be mandatory in all Care
establishments and in my opinion action should be taken to prevent future
deaths and | believe your organisation, has the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 3 March 2014. |, the Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action

is proposed.

_—

; COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the tollowing
Interested Persons, namely the family of the deceased and their solicitor,
Medacs, Geo Amey, the Coroners’ Society Website and the Chief Coroner.

1

!am also under a duty to send the Chief Coroner a copy of your response,

The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to me,
the Coroner, at the time of your response, about the release or the publication
of your response by the Chief Coroner.

6 January Joanne Kearsley
M Area Coroner

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Chief Executive Officer, MEDACS

"| CORONER

| am Joanne Kearsley, Area Coroner for the Coroner Area of Manchester South.

| CORONER'S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.

INVESTIGATION and INQUEST

On the 17" july 2012 | commenced an investigation into the death of Billy Paul
Thomas Salton, date of birth 04.01.1993. The investigation concluded at the end
of the inquest on 27" November 2013. The conclusion of the Inquest was that
the deceased died as a result of 1a) Hypoxic Ischaemic Encephalopathy 1b)
Cardiac Arrest 1c} Epilepsy, and a short form conclusion of natural causes was
recorded.

CIRCUMSTANCES OF THE DEATH

The deceased was an epileptic whose compliance with his medication was, at |
times, variable.

On the 5" july 2012 he presented at Cheadle Police Station where he was
| detained by Greater Manchester Police, He was noted by the Custody Staff to
be an epileptic who was not in receipt of any of his medication. Due to his |
medical condition he was placed in a CCTV cell although there were no }
instructions given to any officers as to how long or when the CCTV should be
monitored.

Medical advice was therefore sought from MEDACS. The deceased was visited
and examined by He was found to be fit to be detained; no
medication was prescribed for him at this stage. In his evidence

indicated that he did ask Mr Salton about when his last fit was, the time before
that and when he was iast in hospital. However he did not record any answers
given on the documentation. He was not in a position to be able to verify Mr

Salton’s prescription with his GP to the time and therefore he did not issue any
medication. He did not enquire as to how long Billy was going to be in custody
and assumed he was being placed before the court in the morning. He did not
therefore set a time for enquiries to be made in the morning with the
deceased’s GP about his medication.

Shortly after this examination Billy had a seizure in his cell; this was un-
witnessed at the time but has been seen subsequently on the CCTV footage.

On the morning of the 5" July the deceased indicated to the police and his legal
representative that he did not feel well and thought he might have had an
epileptic seizure and that he needed his medication. The police therefore
requested a further medical assessment. The deceased was visited on this
occasion by Nurse {J from Medacs. Nurse could not access the
handwritten contemporaneous notes made previously by Dr | This

assessment could not be complet deceased ceased co-operating and
left the medical room when Nurse informed him he could not prescribe

medication.

Nurse EE completed the detained person’s medical form indicating that
the assessment had been completed and the deceased was fit to be detained,
interviewed and transferred. No further enquiries were made to try and verify
his prescribed medication. On handwritten notes made by Nurse

nothing was noted on the detained person’s medical records that the police
should try and obtain medication from Mr Salton’s home address. None of the
police officers on duty recalled Nurse HB cessing this information on to
them.

His GP details were subsequently obtained by his legal representatives who had
re-attended at the police station for the interview. The police verified and
obtained his medication. A third medical request was then made for the
medication to be administered.

Nurse attended in order to administer the medication. She did not
read through all the entries made on the previous Detained Persons Medical
Forms. As she was asked to attend simply to administer medication she did not
carry out an assessment of Mr Salton. However she then completed a Detained
Persons Medical Form indicating that the deceased was fit to be detained,
interviewed and transferred. The deceased was then prescribed his first dase of
medication.

Mr Salton remained in custody overnight. His second dose of prescribed
medications was administered at approximately 6pm. At approximately 8.40am
the deceased had a second un-witnessed seizure in his cell.

Staff from GEO AMEY attended at the police station to transfer Mr Salton to
Court. They had sight of his Prisoner Escort Form (PER) and the Detained
Persons Medical Forms (Form 708) which accompanied him. It was noted by
the GEO AMEY staff that these indicated that Billy was fit to be detained,
interviewed and transferred. It was also noted that he was an epileptic. The
forms were not read thoroughly and in her evidence the escorting officer
indicated that she was unsure that Billy might have had a seizure whilst in
custody, what his level of observations might have been or that he had been

placed in a CCTV cell.

——

At Stockport Magistrates’ Court there was a delay in being able to deal with Billy
in Court. Billy was seen by his legal representatives and at that stage Billy
indicated that he felt OK. He was in a cell waiting to be called to Court. The last
recorded cell check was at 11.56am, (recorded as 12.05 on the computer print
out). Approximately 15 minutes later Billy was found collapsed in the cell. CPR
was performed and he was taken to Stepping Hill Hospital where he died.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless action
is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

1, MEDACS should ensure that all staff are fully aware of the content of any
MEDACS policies or protocols, where these can be located in the police station
and if necessary receive any required training on the same (the Court heard
that was not aware of the MEDACS Epilepsy Policy).

2. MEDACS should receive a verbal report from Custody Staff and as much
information as possible as to the detained person’s medical condition. Even if
they are there solely to administer medication MEDACS staff should read any
previous medical notes from the same stay in custody.

3. All staff are reminded of the need to record information on the MEDACS
Assessment Form including completing a Care Plan. Such a form should be
completed accurately including any negative answers to questions asked.

4. Ifa doctor or nurse is unable to complete a medical assessment or is not
assessing an individual then this should be explained and any potentially
misleading information should not be recorded.

ACTION SHOULD BE TAKEN 7

6
| believe that this level of information should be mandatory in all Care
establishments and in my opinion action should be taken’to prevent future
deaths and ! believe your organisation, has the power to take such action.
7 |Your RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 3 March 2014. |, the Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action

is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following
Interested Persons, namely the family of the deceased and their solicitor, GMP,
GEO AMEY, the Coroners’ Society Website and the Chief Coroner.

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to me,
the Coroner, at the time of your response, about the release or the publication

of your response by the Chief Coroner.

Joanne Kearsley
HM Area Coroner

6" January

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Chief Executive Officer, GEO AMEY

CORONER

| am Joanne Kearsley, Area Coroner for the Coroner Area of Manchester South.

| CORONER'S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations |
2013.

INVESTIGATION and INQUEST

On the 17" july 2012 i commenced an investigation into the death of Billy Paul
Thomas Salton, date o birth 04.01.1993. The investigation conciuded at the end |
of the inquest on 27" November 2013. The conclusion of the Inquest was that
the deceased died as a result of 1a) Hypoxic Ischaemic Encephalopathy 1b)
Cardiac Arrest 1c) Epilepsy, and a short form conclusion of riatural causes was |

recorded.

—

CIRCUMSTANCES OF THE DEATH

The deceased was an epileptic whose compliance with his medication was, at
times, variable.

On the 5° July 2012 he presented at Cheadle Police Station where he was
detained by Greater Manchester Police. He was noted by the Custody Staff to
be an epileptic who was not in receipt of any of his medication. Due to his I
medical condition he was placed in a CCTV cell although there were no |
instructions given to any officers as to how long or when the CCTV should be |
monitored.

Medical advice was therefore sought from MEDACS. The deceased was visited
and examined by Dr Morris. He was found to be fit to be detained; no
medication was prescribed for him at this stage. In his evidence Dr Morris
indicated that he did ask Mr Salton about when his last fit was, the time before |
that and when he was last in hospital. However he did not record any answers |
given on the documentation. He was not ina position to be able to verify Mr

| Salton’s prescription with his GP to the time and therefore he did not issue any
medication. He did not enquire as to how long Billy was going to be in custody
and assumed he was being placed before the court in the morning. He did not
therefore set a time for enquiries to be made in the morning with the
deceased’s GP about his medication. ;

Shortly after this examination Billy had a seizure in his cell; this was un-
witnessed at the time but has been seen subsequently on the CCTV footage.

On the morning of the 5" July the deceased indicated to the police and his legal
representative that he did not feel well and thought he might have had an
epileptic seizure and that he needed his medication. The police therefore
requested a further medical assessment. The deceased was visited on this
occasion by Nurse Kalhoro from Medacs. Nurse Kalhoro could not access the
handwritten contemporaneous notes made previously by Dr Morris. This
assessment could not be completed as the deceased ceased co-operating and
left the medical room when Nurse Kalhoro informed him he could not prescribe
medication.

Nurse Kalhoro completed the detained person’s medical form indicating that
the assessment had been completed and the deceased was fit to be detained,
interviewed and transferred. No further enquiries were made to try and verify
his prescribed medication. On handwritten notes made by Nurse Kalhoro
nothing was noted on the detained person’s medical records that the police
should try and obtain medication from Mr Salton’s home address. None of the
police officers on duty recalled Nurse Kalhoro passing this information on to
them.

His GP details were subsequently obtained by his legal representatives who had
re-attended at the police station for the interview. The police verified and
obtained his medication. A third medical request was then made for the
medication to be administered.

; Nurse Whittaker attended in order to administer the medication. She did not
read through all the entries made on the previous Detained Persons Medical
Forms. As she was asked to attend simply to administer medication she did not
| Carry out an assessment of Mr Salton. However she then completed a Detained
Persons Medical Form indicating that the deceased was fit to be detained,
interviewed and transferred. Tne deceased was then prescribed his first dose of
medication.

Mr Salton remained in custody overnight. His second dose of prescribed
medications was administered at approximately 6pm. At approximately 8.40am
the deceased had a second un-witnessed seizure in his cell.

Staff from GEO AMEY attended at the police station to transfer Mr Salton to
Court. They had sight of his Prisoner Escort Form (PER) and the Detained
Persons Medical Forms (Form 708) which accompanied him. It was noted by
the GEO AMEY staff that these indicated that Billy was fit to be detained,
interviewed and transferred. It was also noted that he was an epileptic. The
forms were not read thoroughly and in her evidence the escorting officer
indicated that she was unsure that Billy might have had a seizure whilst in
custody, what his level of observations might have been or that he had been

placed in a CCTV cell.

At Stockport Magistrates’ Court there was a delay in being aible to deal with Billy
in Court. Billy was seen by his legal representatives and at that stage Billy
indicated that he felt OK. He was in a cell waiting to be called to Court. The last
recorded cell check was at 11.56am, (recorded as 12.05 on the computer print
out). Approximately 15 minutes later Billy was found collapsed in the cell. CPR
was performed and he was taken to Stepping Hill Hospital where he died.

5 | CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless action
is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
| 1. Staff should be reminded of the levels of observation (cell checks) required on
detained persons whiist in their custody. ,
2. Staff should be reminded that ali cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any
documentation available when collecting a detained person. This is especially
1 true of any medical information and if there is a medical reason why someone
is on a certain level / type of observation that this is replicated whilst in the
custody of GEO AMEY.
6 | ACTION SHOULD BE TAKEN

| believe that this level of information should be mandatory in all Care
establishments and in my opinion action should be taken to prevent future
deaths and ! believe your organisation, has the power to take such action.

~

4
YOUR RESPONSE : |

—_ 7

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 3 March 2014. I, the Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action

is proposed.

COPIES and PUBLICATION

i have sent a copy of my report to the Chief Coroner and to the following
Interested Persons, namely the family of the deceased and their solicitor, GMP, |
MEDACS, the Coroners’ Society Website and the Chief Coroner,

ial

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to me,
the Coroner, at the time of your response, about the release or the publication
of your response by the Chief Coroner.

6° January Joanne Kearsley
M Area Coroner

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Greater Manchester Police (PDF)

INQ. 6/4/2018

GREATER MANCHESTER

POLICE

Sir Peter Fahy Q.P.M., M.A.
Chief Constable

Ms Joanne Kearsley
Area Coroner

The Coroner Court

1 Mount Tabor Street
Stockport

SK1 3AG
04 March 2014

RE: Mr. Billy SALTON (Deceased)

Thank you for your report dated 6"" January 2014. In accordance with the contents of your
Regulation 28 report in respect of Billy SALTON, | reply to the matters you have asked me to

consider as follows;

7. During the course of the evidence, | heard that Billy Salton had remained in custody
overnight and was not progressed as quickly as he could have been whilst in custody as
there was no-one available to interview him. This is as a result of GMP policy on how people
are progressed through custody. The Prisoner Processing Unit (PPU) is not staffed
overnight which leads to people being in custody longer than they should be and bringing
GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot
indicate how many people may have been detained in custody longer than they should have

been under their new policy.

Divisional Commanders hold responsibility for staffing their PPUs overnight but the reality is
there are very few detainees who can appropriately be interviewed in the night. Indeed many
other agencies are not configured to deal with interviews during the night. The Appropriate
Adult Scheme, as just one example, will not turn out in night time hours as they believe it is

always inappropriate to interview a person who may be tired.

In the case where there are no PPU officers on duty to interview, it is the Custody Sergeant’s
responsibility to liaise with the Operational Inspector, who acts as Bronze Command for that
Division, to agree on resource provision to ensure the effective progress of the investigation.
As you observed this often leads to a decision being made to await interview in the morning
because the police officers are patrolling and dealing with incidents.

! acknowledge that such delays in custody, whilst waiting for an interviewing officer to be
identified, have become increasingly common. | have an ongoing review of divisional policing
entitled ‘Transforming Divisional Policing’ which looks at all aspects of improving the
operational service we provide. | have specifically asked it to look at finding ways of
processing detainees with greater efficiency in order to reduce their periods of detention.

GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP Tel: 104

Cont.d page 2....

2. There was a lack of understanding amongst the custody staff and staff from other
agencies as to the level of observations Mr Salton was on and why he was on those
observations. It is important that everyone who has care of someone in custody understands
what the observations have been, what they should be, when they are to be carried out,
whether rousing is required and why the observations are set as they are — i.e. what the

medical condition/concern is.

GMP has reviewed its arrangements for communication between custody and clinical staff to
negate the practice of MEDACs staff working on two separate records of notes and to
improve the continuity of care provided to detainees with health needs.

This has involved the installation of a computerised system for use by MEDACS Clinicians,
which operates within prescriptive rules requiring MEDACS to type the 708e to overcome
issues of illegibility, improve continuity and to seek to ensure the details of the record are

directly transcribed into the ICIS custody system.

To improve clarity on levels of observations we have amended the ‘drop down’ menus
accessible to the MEDACs clinicians attending custody suites. Plans are in place to enable
MEDACs to directly input their care plans onto our custody system which will further improve
communication between custody and clinical practitioners.

A training programme for all clinicians has been agreed which will ensure they are trained
and authorised to input onto ICIS by summer 2014.

We accept there continues to be room for improvement in communication in the custody
office and have engaged a work programme enabling Custody Sergeants to do more
managing in the custody environment and to take a greater overview of the overall working of
the office and CDO's. In practice, for example, this would entail the Civilian Detention
Officers undertaking specific sections of the ‘booking-in’ process which facilitates a greater

overview of the entire custody environment both front office ice. This programme
is bedding in under the leadership of Chief Superintendent and Superintendent

3. When the detainee is visited and checked all such visits should be accurately recorded on
the custody record.

We already have a process that checks custody records to ensure visits are timely and
carried out in accordance with the sergeant’s risk assessment.

It is though more difficult to check on visits that have been made but not recorded although
this sometimes arises when cases are reviewed. It is commonplace for staff to Say that there
are so many interactions in custody, at some point, they have to take a view on what is

worthy of recording.

! do agree with this but can see how this can degrade into quite significant events not being
accurately recorded. We will, therefore, shortly be giving a series of inputs to staff which will

GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP_ Tel: 101

Cont.d page 3 ....

focus on recording the rationale behind risk assessments and will also demonstrate to staff
the importance of recording their actions as accurately as possible. The Professional
Standards Branch will be involved in this programme, which will involve the use of case

studies to enhance best practice.

4. Risk assessments carried out whilst in police custody should be recorded when they are
done. If there are no changes to a risk assessment then this should be recorded and any

rationale noted.

Since the death of Mr Salton, Custody Branch has significantly upgraded its ICIS computer
system. This system prompts Custody Sergeants to undertake further reviews linked to
specific/significant events affecting the detainees period of detention, including an exit risk

assessment.

You are right to point out that all risk assessments, including those where there is no change
in the detainee’s circumstances, should also be recorded. This requirement has been
communicated to custody staff and is currently being monitored by Custody Inspectors

undertaking dip sampling of custody records.

5. Handovers between Custody Sergeants were ineffective and there was no handover
between the Civilian Detention Staff. Important information was missed or lost in translation.
Proper handovers should take place as to the detained person's condition, risk assessment,
any medical condition, levels of visits and other important matters.

We have conducted a review of handovers between sergeants. As a result we have made it
clear to sergeants that the handover need not be a comprehensive review of each detainee.
Rather, they should have completed the Custody Summary Screen so that all the relevant
detail is available on the ICIS system and the handover should contain key risk issues, for

example medical conditions, medication required and so forth.

It is now our operating policy that this summary screen should be accurate so that staff use
the computer to ascertain key information and work from this.

The work programme, mentioned above, also seeks to improve communication channels in
custody amongst Custody Sergeants and Custody Detention staff both during handover and

during the working day.

6. The Prisoner Escort form (PER) was incorrectly completed. The final Custody Sergeant
should ensure that the transferring documentation is accurate.

Since your observations we have put out improved guidance on completion of the PER form
to sergeants which include what to record, when it is to be done and how it is to be signed
off. This has been extensively checked and has led to improvements in standards.

GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP_ Tel: 101

Cont.d page 4 .....

7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell.
The CCTV screen is situated furthest away from the desk where someone in the back office
is more likely to be seated (next to the security controls) meaning that there is less likelihood
of them “glancing“ at the CCTV screen.

At present we remain satisfied with our current arrangements for CCTV usage. We do use
CCTV for constant observations in some cases. However, in the case with Mr Salton, the

level of observations was at Level 2.

We see CCTV as something that adds value to the care plan in such situations but would not
want to commit to specifically instructing staff to observe the screen at this level of
observations. In the way we currently operate, we believe, this may lead to a deterioration in
the level of coverage of detainees by CCTV. | also am keen that CCTV use never becomes
an alternative to the necessary personal contact between my staff and detainees.

We are currently happy that the CCTV is optimally placed to be viewed by all staff who work
in Custody.

The programme of work | described earlier in improving communication and management of
the office is looking at every aspect of the roles staff undertake in Custody. The monitoring of
CCTV is one of those roles and they will be looking for a system that matches or improves
the coverage of CCTV we have and also provide greater accountability.

On a final general point | am concerned that Custody, which is primarily a function to achieve
criminal justice outcomes, is increasingly being used to deal with issues and matters that do
not lie within the scope of policing. | acknowledge that we should always strive to achieve the
best possible care for all detainees. However, we are undoubtedly picking up the gaps in
services which should be provided by other agencies. This takes our attention and resources
from policing but also places officers, who are not medically trained, in increasingly difficult

situations.

As a force we are working with other agencies, particularly the NHS, to reduce the number of
those with mental illness or other medical conditions coming into custody. Long term this
would ideally include a facility to deal with drunken individuals. In this day and age the
concrete rooms of a custody block are not suitable places for sick people.

Toran ia)

Sir Peter Fahy
Chief Constable

GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 58P Tel: 101

Response from Medacs (PDF)

medacs

Ms Kearsley

Area Coroner

The Coroners Court
Mount Tabor
Mottram Street
Stockport

SK1 3PA

Date 24 February 2014
Your Ref: JK/KA/01544-2012

Dear Madam

RE: Prevention of Future Death Report following the Inquest into the death of Billy Salton

| write in response to the Prevention of Future Death report dated 6 January 2014. | have considered your
letter and my response will address each of the matters of concern which you raise:

Staff access to Medacs Policies and Procedures
Information from the custody staff and previous medical entries
Correct completion of the Medacs assessment form

When an individual is not assessed by a Medacs clinician

Rw

1. The access of Medacs Policies and Procedures to Medacs staff

| was also concerned to hear that [EE was not aware of the Medacs Epilepsy Policy. He said in evidence
that he had no specific recollection of the epilepsy policy, but he was aware that the Medacs policies were
available in a ‘loose leaf binder in most custody suites’. Asa very experienced FME JJ gave evidence
that he had been asked to review most of the policies, but he could not specifically recall this one.

! agree that it is important that all staff know where to look to seek guidance and where the policies are to
refer to. | would like to reassure you that before they start work alone, all new healthcare staff complete a 3
day shadowing period with an experienced clinician. During this 3 day period they are made aware of the
content of the Medacs policies and procedures and how these can be located whilst on duty and they are now
required to sign to say they have had this information. All policies and procedures are located in every custody
suite in both hard copies ina file and on the desktops of the medical room computers. Every time a policy is
reviewed or revised a communication is disseminated from the Head of Clinical Services via all lead clinicians
by e-mail and the relevant policy is updated in the folder and the desktop. The Medacs medical room audit
that is undertaken by the Lead nurses every 3 months includes a standard for ensuring the policies and
procedures are in both hard and soft copies in all custody suites.

v| sta
Recruitment &

150 9001-2008 | Sethe
=. Confederation

Medacs Healthcare
Quay Plaza, Salford Quays, Salford, Greater Manchester MSO 3BA ___ Medacs Healthcare plc, an Impellam Group Company
Registered Office: 800 The Boulevard, Capability Green, Luton, LU1 3BA

Tel: 0161 772 8485 Fax: 0161 772 8497 Registered in England No. 2518546

medacs
Ge

2. Information from the custody staff and previous medical entries

You advise that Medacs clinicians should receive as much information as possible from the custody staff about
the detainee’s medical condition and that even if they are there to solely administer medication, they should
read any previous medical notes from the same stay in custody. | am also keen to ensure that medical staff
have all the relevant information that they require in order to administer medication, and that they read other
relevant information which is available. Medacs staff are required to receive a verbal handover from the
custody sergeant before seeing any detainee. This has been explained more fully in policy, and is included
specifically in the Medacs Foundation course.

Since this Inquest a new procedure has been ratified: ‘Pre and post clinical assessment guidelines for HCPs
reviewing detainees in police custody’ which includes that

e “The HCP should discuss with the custody sergeant what medical history they have gathered from the
DP whilst completing their risk assessment, including any medication the DP has in their property in
custody or at home and whether the DP has taken any medication prior to coming into custody...|t is
important that following this history gathering a decision is made to whether the DP requires this
medication for the time they may be held in custody and collection of this medication is requested at
this time to the custody sergeant. Record this on the medical assessment form on the care plan and on
the history front sheet.’

e The HCP should read any previous entries on the custody medical assessment form to gather any
further history that was given on previous arrests/ calls and enable them to start to build a history and
management of the DP whilst in custody

e The HCP may also note any changes in circumstances and health of the DP and where necessary
initiate referrals to the multi service providers to encourage continuity of care at the time of release

To ensure all staff are aware of this, an email was sent to all clinicians from the Head of Clinical Services in
January 2014 and reminding them of the importance of pre and post assessment actions for all detainees
before and after they conduct their clinical assessment.

3. Correct completion of the Medacs assessment form

| note your advice to remind staff of the importance of recording information on the Medacs assessment form,
including a care plan and any negative answers to questions asked. | agree with you that it is important for
staff to record significant negatives answers, as the tendency can sometimes be to record the positive answers
they receive only. Unfortunately, it is not possible for staff to make a record of every question asked, and
every answer given, or refused to be given, but the significant information must be recorded.

Clinicians are trained and audited on the use of “Medacs FME” system (the electronic record system in all
custody suites) and ‘The use of Medacs FME Clinical Form’ is covered in the foundation training and Induction
Training which includes reminding staff of the importance of completing all boxes even if there is nothing to
report or a negative answer received. Care plans are recorded by the clinician on the computer and printed

off for the police

5] sta

sso eoraeee | L=Seae Employment
= Confederation

Medacs Healthcare

Quay Plaza, Salford Quays, Salford, Greater Manchester M50 3BA wiaaciaica bie ae eet BG Snipe Group Company
‘ ; egistered Office e Boulevard, Capability Green, Luton, LU1 3BA

Tel: 0161 772 8485 Fax: 0161 772 8497 Registered in England No. 2518546

medacs
[HEALTHCARE]

In May 2013 Medacs commenced a weekly audit of the ‘use of computer system’ The Client Service Managers
address any issues identified with the clinicians. This is a continuing task.

Lead Doctors and Lead Nurses have been tasked with completing annual audits of the quality of the medical
notes of all clinicians in their teams, and have been asked to address any concerns on an individual basis with

staff. A re-audit is due in June 2014.

Medacs are in the process of reviewing the electronic MedacsFME system to include screening tools and
dropdown boxes that will make it impossible to move onto the next section without completing the

information.
4. When an assessment cannot be completed fully

| note your recommendation that if a clinician is unable to complete an assessment that this should be
explained and ‘any potential misleading information should not be recorded’. Given the nature of the work in
police custody, our healthcare staff frequently attend to assess detainees who refuse to co-operate. In most
cases it is for the detainee to decide whether they consent to an assessment, or choose to refuse, or answer
questions about their health. Our Investigation report identified that in this case a nurse circled “completed”
on the handwritten form re: “examination/observations completed/refused”. Mr Salton had answered some
questions, but refused to answer others. The handwritten forms are no longer used, and the electronic record
system does not ask the staff member to select either ‘complete’ or ‘refused’. The electronic record system
means that the clinicians Care Plan is printed out and given to the custody sergeant: this reduces the risk of
different information being written in the clinician’s own records, to that written on the paperwork for the

police.

| was of course aware of the Inquest as it proceeded, but thank you for bringing these matters to my attention.

Yours faithfully

Medacs Healthcare Plc

Re

Recruitment &
150 9001:2008 Employment
Confederation

Medacs Healthcare
Quay Plaza, Salford Quays, Salford, Greater Manchester M50 3BA Medacs Healthcare plc, an Impellam Group Company
Registered Office: 800 The Boulevard, Capability Green, Luton, LUi 3BA

Tel: 0161 772 8485 Fax: 0161 772 8497 Registered in England No. 2518546

The report

Responses

Related reports

Other reports by Joanne Kearsley

More reports categorised “State Custody related deaths”

Track State Custody related deaths