Responding to the annual IPOC report on deaths in Police Custody

On 28 July, the latest annual statistics on deaths in police custody generated headline news. The figures, collected by the Independent Office for Police Conduct (IOPC), showed that 23 people died in police custody in 2022-23, much higher than the recent trend.

Table: Deaths in or following Police Custody

Source: IOPC, 28 July 2023

The IOPC’s acting director general, Tom Whiting, said: “Sadly, we have seen a significant rise this year in the number of deaths in or following police custody, up to 23 from 11, and the highest figure recorded for five years. While last year’s figure was particularly low, the fact we have seen a sharp reverse is concerning and raises challenges which spread well beyond policing.”

Vulnerability due to mental health

As in recent years, the majority of cases were connected to mental health and use of alcohol and drugs:

• Thirteen of 23 people who died in or following police custody had mental health concerns.
  

• Twenty-one people who died in or following police custody had links to drugs and/or alcohol.
  

• Almost two-thirds (55) of those who died following other police contact were reported to have mental health concerns.
  

• A similar proportion (55) were reported to be intoxicated with drugs and/or alcohol at the time of the incident, or it featured heavily in their lifestyle.
  

• Sixteen fatalities following other police contact related to concern about a person’s risk of self-harm, suicide, or their mental health. A further twelve people were reported to the police as missing, with a specific risk of self-harm or suicide.

Risk of ineffective collection and sharing healthcare information

We can put the IOPC data together with evidence collected by other authorities. The importance of effective information on healthcare in police custody is clear.

There have been 20 reports from coroners, for example on police related deaths since October 2021. Of these, coroners raised concerns over poor recording or sharing of health information in five cases.

NHS England publishes independent investigation reports to establish what lessons are to be learned from a case of homicide, suicide or serious harm. A key theme of concern is inadequate handovers between agencies, based on incomplete healthcare information.

The police and prisons inspectorates carry out regular inspections of police custody suites. There were 10 in 2022 and 2021. In seven of the 10 cases, the inspectorates raise concern over the transfer of information between custody and detention officers.

Improving outcomes – SONAR and Right Care, Right Person

SONAR is specifically designed to address these concerns and so to improve health outcomes. It can connect healthcare information in police custody both to NHS data and to other areas of the criminal justice system. It aims not only to improve data collection but also to remove the problems of transition and handovers.

The best way to implement SONAR would be for NHS England to commission a single electronic case management system across all 42 police forces, using the same procurement framework as those currently used for general practice and health and criminal justice (GP IT Technical Innovation Framework (TIF) and Health & Justice Information Services, HJIS2). This would integrate health information across the forces and open the door to shared information across health and justice.

Tom Whiting also emphasised the importance of providing effective mental health support for vulnerable people. The IOPC will monitor the Right Care, Right Person scheme, by which people with mental health needs will be responded by mental health professionals rather than police officers. The scheme was developed by Humberside Police and is now being rolled out nationwide.

Conclusion

This year’s statistics were a shock to all those concerned with improving healthcare in justice settings. Let’s hope they can be a catalyst for a better way forward.

SONAR and Resettlement

One of our motivations in developing SONAR was to bridge the gap between healthcare systems in different parts of criminal justice - to leave the silos behind. Failures of information transfer between agencies are a regular cause of serious harm as attested by coroners’ reports.

An example is the transition between prison and probation - sometimes called “resettlement”. As the Permanent Secretary of the Ministry of Justice said in June, the latest data on resettlement is “encouraging”: over the last decade, the proportion of prisoners that reoffend within twelve months has fallen from 50 per cent to 38 per cent. The question is how to do even better, and we think SONAR can help.

One area where progress is needed is access to healthcare information, which is at the heart of the SONAR offer. Writing in May, the National Audit Office pointed out that the NHS does not always share prison leavers’ healthcare records and data with outside agencies without consent, including probation services. As a result, prison and probation staff do not necessarily know whether someone has been referred for drug treatment on release. HMPPS told the NAO researchers that this can hinder probation staff from ensuring that prison leavers engage with treatment.

For the NAO, participation in drug treatment is one of the key measures of resettlement (along with employment and settled accommodation). Only 37 per cent of prison leavers with a substance misuse treatment referral were engaged in community-based treatment within three weeks of release in 2021-22, the most recent data available.

SONAR is designed to solve precisely these problems. SONAR Secure (holding healthcare information for prisons and other custodial environments) and the SONAR Release Support Hub (for people transitioning back into the community) share information seamlessly. They comply fully with NHS and criminal justice standards on privacy. The Release Support Hub is designed to support probation teams after release - for example, by flagging when an ex-offender has missed a medical or other appointment.

Levels of reoffending have fallen but the cost of reoffending to society is around £17 billion per year on the last Ministry of Justice estimate. As the NAO report said: “Prison leavers are more likely to reoffend if they are not resettled into the community, for example if they have nowhere to live, no job or other income, and have poor continuity of healthcare.” Let’s see what we can do to help.

SONAR CMS – Right Care, Right Person, Right Software

Thank you for your interest in SONAR. I hope this monthly blog will keep you informed as we build the first Health and Social Care Case Management System (SONAR CMS) that provides contemporaneous notes, tasks and actions for those in the Criminal Justice system – through Police Custody and Courts (SONAR Custody), Prison including HMP, YOI, STC, SCH and IRC (SONAR Secure) and for people transitioning back into the community, after being held, the SONAR Release Support Hub. These different software modules seamlessly interact with each other or can stand independently of each other. All modules feed into our SONAR Data Portal for all of your business and management information requirements, data visualisation, analytical trends and real time reporting needs.

It has been an exciting journey so far. SONAR is the only NHS Digital (now NHS England) authorised H&J CMS solution with connections into the NHS Spine for the Personal Demographics Service (PDS) and Summary Care Records (SCR). We are working to bring online other key Spine services.

In addition, SONAR already has some limited access to the existing Secure Estate healthcare records and was recently awarded a place on the GP IT Tech Innovation Framework (GP IT TIF). With this design, connectivity and development roadmap, SONAR CMS will be the go to software for a case management system for Health and Social Care in Criminal Justice in the United Kingdom and potentially beyond.

Building SONAR is a labour of love for our team but, more importantly, an answer to longstanding challenges in criminal justice.

The Government is rightly committed to a zero-tolerance approach to deaths in custody, be it Police, Court or Prison. But there remains one area of provision which consistently leads to death and harm: the poor recording of health data and the absence of shared health information between police forces, between Police and Courts and between Courts and Prisons. Not to mention any of these CJ settings and the wider NHS community, e.g. Mental Health Trusts.

25 per cent of coroners’ reports on police related deaths since October 2021 have highlighted these issues. In one case, Dorset Police attended a person with serious mental health needs who had been in contact with Avon and Somerset Police earlier that day. Dorset Police were unaware of the contact with the other force. The coroner noted: “there is no means to share information automatically across Police forces regarding concerns raised about a person's welfare or health”. She concluded:

“Greater sharing of information therefore between Police forces in England and Wales regarding the welfare of those who come into contact with the Police could prevent future deaths. Evidence was given that it would be wholly beneficial, both within the Police and the NHS, if systems were able to talk to one another.”

As the Advocacy page of our website (http://www.sonarcms.co.uk/advocacy) explains, we believe one change in policy could make a positive difference.

At present electronic medical record systems, for the recording of healthcare interventions and outcomes, are commissioned separately by individual Police and Crime Commissioners. A positive change would be for single organisation, ideally NHS England, to commission a single Health and Social Care case management system across all 42 forces, using the same new procurement framework as that being used for the future of general practice information technology (“GP IT Technical Innovation Framework (TIF)”) and potentially for healthcare within other criminal justice settings (“Health & Justice Information Services, HJIS2”).

This would be a major step towards the creation of a shared care record across criminal justice and the NHS. It would also be consistent with the recommendations of the Report of the Independent Review of Deaths and Serious Incidents in Custody by Dame Elish Angiolini, which argued for a “consistency of approach” between forces on medical services within police stations, “something that is potentially undermined by the current fragmented approach”. It argued that “medical services within police stations to be brought within the NHS, in the same way they are in prisons”.

I am committed and proud to be part of the community of people, including the SONAR team, that strives to improve the lives of people in the criminal justice system. I hope this regular blog can help to build that community further, so that together, we can improve outcomes even further.