Recommendation - Greater Manchester Police, July 2025
We found organisational learning following a death and serious injury investigation regarding a detainee who had some known history of self-harm.
IOPC reference
Recommendations
The IOPC recommends that Greater Manchester Police (GMP) should, as part of their action to replace their custody system, review their provision for risk assessment completion. This includes consideration of adding prompts for custody officers to carry out risk assessments at trigger points for self-harm. These trigger points include but are not limited to:
- return from interview
- being charged
- being remanded in custody
Greater Manchester Police may also wish to consider whether these prompts should include offering support services at those times.
This recommendation has arisen because of a death and serious injury investigation regarding a detainee who had some known history of self-harm. The detainee had been in custody for 18 hours when a decision was made to charge and remand him in custody. Half an hour later he self-harmed, becoming unconscious in his cell. He was noticed by a Detention Officer and a Health Care Professional attended. He was transferred to hospital, where he recovered.
There was no audit of a risk assessment carried out after he was charged and remanded in custody in accordance with the College of Policing’s Authorised Professional Practice.
Accepted
GMP have submitted to the developers of the Mark43 RMS system (identified replacement iOPS computerised custody system) that it has the following automated triggers for risk assessment completion during detention:
- upon arrival in detention
- at handover
- following contact with family/acquittance
- return from interview
- return from hospital
- post HCP assessment
- at point of charge
- at remand following charge
- at point of release from detention
When selecting identified risks, the custody officer will be prompted with additional guidance, contact details and tool tips, for example contact details for Samaritans.
The Mark43 system will be completely configurable so that any amendments to legislation or Authorised Professional Practice (APP) can be accommodated swiftly.
With no firm anticipated delivery date for the Mark43 system, GMP custody staff in the interim period are trained to follow the guidance in the College of Policing APP to undertake self-generated risk assessments at the activity points mentioned above.