Care of a man while in custody - Avon and Somerset Constabulary, May 2018
On 28 May 2018, Avon and Somerset Constabulary officers arrested a man on suspicion of common assault. They took him into custody in Bristol, where his detention was authorised. The man had type 1 diabetes, and had insulin and other medication in his possession when he was booked into custody. The man disclosed he had mental health issues and had stopped taking related medication, and was also using drugs.
The man was initially placed under ‘level 3’, constant observations, to include physical checks and visits to his cell at least every 30 minutes and constant CCTV monitoring.
The man was seen by a healthcare practitioner, who recommended he be put under ‘level 1’, general observation (requiring checks at least every hour with minimal intrusion), and advised he should be monitored for symptoms of hyper/hypoglycaemia such as sweats, excessive thirst, confusion, disorientation, vomiting. The man was not given insulin in custody because he refused to eat. His blood sugar levels were monitored and found to be high, but within the acceptable margins.
On the evening of 29 May 2018, the man was transferred to a mental health unit under Section 2 of the Mental Health Act 1983. Following his arrival, his blood sugar level continued to rise until it was dangerously high. He was taken by ambulance to Bristol Royal Infirmary, where he received treatment for diabetic ketoacidosis; a potentially life-threatening complication of diabetes.
Our investigators analysed CCTV footage and compared the contents to information recorded on the custody record. They obtained statements from healthcare professionals and custody staff involved in the man’s care.
While we identified a number of concerns in relation to the care provided to the man, there were no indications suggesting that any individual acted intentionally or maliciously. The evidence suggests that at least some of the failings may have been due to a lack of awareness (for instance in relation to conducting checks on detainees via the spyhole), poor communication (particularly during handovers), and poor record-keeping.
We were of the opinion that the failings of one detention officer, who missed several instances of the man appearing distressed, unwell or in need of assistance, and making repeated efforts to attract attention via CCTV, would justify formal Unsatisfactory Performance Procedures (UPP).
We identified a number of areas of learning for the force around spyhole checks, risk assessments, care plans, the importance of accurate and detailed custody record entries, medical checks, and reinforcing training around dealing with detainees with diabetes.
We completed our investigation in March 2019.
After reviewing our report, Avon and Somerset Constabulary advised that the custody officer would receive management action under UPP. The force also advised that they would deliver a learning debrief to their custody teams based on our report, as well as training for all custody staff on the management of diabetes. All staff will also be reminded that spy-hole checks are not allowed.