Report on an inspection visit to police custody suites in West Midlands Police

Summary

This report describes our findings following an inspection of West Midlands Police custody facilities. The inspection was conducted jointly by HM Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) and the Care Quality Commission (CQC) in May 2023. It is part of our programme of inspections covering every police custody suite in England and Wales.

The inspection assessed the effectiveness of custody services and outcomes for detained people throughout the different stages of detention. It examined the force’s approach to custody provision in relation to detaining people safely and respectfully, with a particular focus on children and vulnerable adults.

To help the force improve, we have made four recommendations to it and its police and crime commissioner. These address our main causes of concern.

We have also highlighted a further 16 areas for improvement. These are set out in section 6 of this report.

Leadership, accountability and working with partners

West Midlands Police has clear governance arrangements for the provision of custody, with strategic and operational meetings to oversee and manage custody services. Since our last inspection in 2017, governance structures have improved. But despite this, oversight of custody still isn’t strong enough, with limited progress in improving custody provision. Overall leadership of custody is a cause of concern.

The force had recently re-opened two of its custody suites and changed how it operates to provide more local custody facilities and help meet demand from the increasing number of detainees entering custody. The changes were being introduced when we carried out our inspection, so it is still early days to assess how well they are working. However, we found personnel sometimes struggling to provide custody services and meet the needs of detainees.

The force has adopted the College of Policing’s APP (authorised professional practice) guidance but this isn’t always followed, especially for risk management. Neither is the force consistently following PACE (Police and Criminal Evidence Act 1984), its codes of practice and other legislation. It is a cause of concern.

The force collects and monitors a range of performance information. However, some important information to show how custody services perform across a wider area – such as reviews of detention, or detainee care – isn’t collected to help assess outcomes for detainees.

The governance and oversight of the use of force in custody isn’t good enough. Use of force is monitored at governance meetings but the information to support effective scrutiny is limited and poorly recorded. In the cases we reviewed on CCTV we found that incidents weren’t always managed well. The force can’t show that when force or restraint is used in custody, it is necessary, justified and proportionate. This hasn’t improved since our last inspection and is a cause of concern.

The quality of recording on custody records is often poor. Quality assurance arrangements to review custody records and assess how well custody services are provided aren’t robust enough and don’t cover enough custody activities.

However, the force assesses some of its services to identify any disproportionality, for example in the use of strip searches, and is also open to external scrutiny from others.

The force has a priority to divert children and vulnerable adults away from custody and the criminal justice system. It works with partner organisations to achieve this, including the St Giles Trust, which supports children in and after custody. There is also work with mental health services to help people with mental health conditions who come to police notice or are arrested. However, outcomes for most of these people remain poor.

Pre-custody – first point of contact

Frontline officers have a good understanding of how a person may be vulnerable and take account of this when deciding whether an arrest is appropriate. Information from call handlers to help officers decide what to do varies but is generally good. Children are only arrested when all other alternatives, such as voluntary attendance interviews, have been explored.

There isn’t always enough help for frontline officers dealing with people with mental health conditions. A team of police officers trained in mental health provide advice and assistance, but they aren’t available 24 hours a day, so officers sometimes make their own decisions about whether to detain someone under section 136 of the Mental Health Act 1983. Frontline officers told us they spent a long time at hospitals with people in mental health crises, waiting for them to be transferred to the care of the health service.

In the custody suite – booking-in, individual needs and legal rights

Custody staff interact respectfully with detainees and are patient and reassuring. But detainee privacy isn’t always protected because sensitive conversations can be overheard in some suites, and detainees aren’t offered the opportunity to speak with someone in private. When a detainee’s clothing is removed their dignity isn’t always maintained.

Custody staff recognise and do their best to meet detainees’ individual and diverse needs. But facilities in the suites sometimes make this difficult, with few adjustments for detainees who have physical disabilities or hearing or visual impairments. The needs of women aren’t always met and custody personnel’s understanding of how to handle religious items could be better.

Identification of detainee risks is generally good and observation levels usually reflect the risks posed. Checks on detainees are mainly carried out on time and in the right way.

However, the force isn’t following APP guidance in all areas. For example, footwear and clothing with cords are routinely removed rather than justifying this through an individual risk assessment. Handovers between shifts aren’t carried out collectively to make sure risk information is fully shared among all custody personnel. The management of detainee risk is a cause of concern.

Custody officers don’t always have enough information when deciding whether to authorise detention, and some detainees spend longer than necessary in custody because their cases aren’t dealt with promptly. Reviews of detention aren’t carried out well enough, and little attention is paid to how the case is progressing. Many aspects of reviews don’t meet the requirements of PACE code C.

Not all custody officers explain to detainees their rights and entitlements well enough, or give detainees information to help them understand these rights. While the force provides rights and entitlements correctly in some areas, for example the rights specific to foreign nationals, in others, it isn’t consistently meeting the requirements of PACE code C.

In the custody cell – safeguarding and healthcare

The force has six custody suites at Perry Barr, Oldbury, Coventry, Wolverhampton, Stechford and Bloxwich. They are generally clean and well maintained. But there are potential ligature points in all of them. Many of these were there when we last inspected, and little action has been taken to mitigate the risks from them.

The approach to detainee care is mixed. Staff have a caring attitude and the detainees we spoke to were positive about the care given to them in custody. But detainees aren’t always advised of the care provision available to them so don’t know what they can expect. Although food and drink are offered, few detainees are offered showers, exercise, reading material or distraction activities.

There are arrangements to safeguard detained children with referrals made to local youth offending teams to consider what should happen and assess any support needs. However, same-sex members of staff aren’t assigned to oversee the care of girls in custody as required by the Children’s and Young Persons Act 1933. Children and vulnerable adults don’t always receive support from appropriate adults (AAs) quickly enough.

Children are only detained when necessary but there isn’t enough focus on keeping their time in custody as short as possible. There are facilities at Perry Barr and Oldbury to help children cope better with the custody environment, but little else is offered or made available to help meet their needs. The lack of available alternative accommodation arranged through the local authority means most children charged and remanded remain in custody rather than moved as they should be.

Experienced and competent healthcare practitioners (HCPs) carry out prompt clinical assessments and provide good health treatment for detainees. Support for detainees with substance misuse needs is good. Medicines are stored and administered appropriately.

Support for detainees with vulnerabilities and mental health conditions varies between custody suites. Apart from at Coventry, there aren’t enough liaison and diversion (L&D) practitioners to always see detainees in person or meet their needs promptly. When a detainee needs an assessment in custody under the Mental Health Act 1983, there are long delays, and further delays if the detainee needs to go to a mental health facility. The force regularly detains people under section 136 of the Act to move detainees from custody to a hospital.

Release and transfer from custody

Pre-release risk assessments are carried out with the detainee present, but they aren’t always thorough enough to make sure all risks are considered and discussed with the detainee prior to their release. Not all detainees are given support leaflets when leaving custody, and arrangements to help them get home are limited.

When detainees are remanded, they are generally transferred promptly to the next available court. This keeps their time in custody to a minimum.

Causes of concern and recommendations

Introduction

This report is one in a series of inspections of police custody carried out jointly by HMICFRS and CQC. These inspections are part of the joint work programme of the criminal justice inspectorates and contribute to the UK’s response to its international obligations under the United Nations Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT).

The national rolling programme of police custody inspections, which began in 2008, makes sure that custody facilities in all 43 forces in England and Wales are inspected regularly.

OPCAT requires that all places of detention are visited regularly by independent bodies – known as the National Preventive Mechanism (NPM) – which monitor the treatment of, and conditions for, detainees. HMICFRS and CQC are two of several bodies making up the NPM in the UK.

Our inspections assess how well each police force fulfils its responsibilities when detaining people in police custody, and the outcomes for them. This includes how safely they are managed and how respectfully they are treated.

Our assessments are made against the criteria set out in our Expectations for police custody. These standards are underpinned by international human rights standards and are developed by the two inspectorates. We consult other expert bodies on them across the sector and they are regularly reviewed. This helps to achieve best custodial practice and promote improvements.

The expectations are grouped under five inspection areas:

• leadership, accountability and working with partners;
• pre-custody – first point of contact;
• in the custody suite – booking-in, individual needs and legal rights;
• in the custody cell – safeguarding and healthcare; and
• release and transfer from custody.

The inspections also assess compliance with the PACE 1984, its codes of practice and the College of Policing’s Authorised Professional Practice – Detention and Custody.

The methodology for carrying out the inspections is based on:

• a review of a force’s strategies, policies and procedures;
• an analysis of force data;
• interviews and focus groups with personnel;
• observations in suites, including discussions with detainees; and
• an examination of case records.

We also analyse a representative sample of custody records from all suites in the force area for the week before the inspection starts. For West Midlands Police, we analysed a sample of 100 records. The methodology for our inspection is set out in full at Appendix I.

Terminology in this report

Our reports contain references to, among other things, ‘national’ definitions, priorities, policies, systems, responsibilities and processes.

In some instances, ‘national’ means applying to England and Wales. In others, it means applying to England, Wales and Scotland, or the whole of the United Kingdom.

Section 1. Leadership, accountability and working with partners

Expected outcomes: Leadership, accountability and working with partners

Chief officers have a clear priority to protect the safety and well-being of detainees and to divert vulnerable people away from custody.

Leadership

West Midlands Police has clear governance arrangements for the provision of custody services. An assistant chief constable has overall responsibility for custody, with a chief superintendent as head of criminal justice. A superintendent and a chief inspector responsible for custody supports them.

There are strategic and operational meetings to oversee and manage custody services. These include:

• the crime governance meeting chaired by the assistant chief constable, which considers matters referred from other custody meetings and provides strategic oversight of the service;
• the custody governance board, which considers custody matters in detail, such as cell occupancy levels. It includes representatives from other departments, such as estates, finance and procurement, and prioritises and tracks actions to improve services;
• service improvement meetings, which consider how improvements can be made and progress against these, for example addressing concerns around strip search decision-making; and
• weekly meetings between the superintendent and the custody inspectors to manage and monitor current priorities for improvement, for example examining decision-making processes and accurate ethnicity recording.

Governance structures have improved since our last inspection, and we found senior leaders actively involved in seeking to improve custody provision. But despite this, there has been limited progress since our last inspection in 2017. Significant concerns remain. Overall leadership of custody services is a cause of concern.

However, physical healthcare for detainees has improved and the force manages the contract for the service with Mountain Healthcare Limited well.

The force has a strategic priority to tackle crime and increase arrests. Information provided by the force shows arrests are rising. This means demand for custody services has also risen. The force has increased the number of its suites from four to six and has changed how it operates to meet the increased demand and provide custody more effectively. The changes were being introduced at the time we carried out our inspection, so it is still too early to assess how well they are working. However, we found personnel sometimes struggling to provide custody services and meet detainees’ needs.

On 2 May 2023, the force reopened two custody suites at Bloxwich and Stechford to help manage the increase in detainees, and to have more local custody suites to reduce travel times. Existing custody personnel have been re-distributed across the suites with cell capacity limited at the two larger suites at Parry Barr and Oldbury to allow this. The force is keeping these arrangements under constant review to assess how well they are working and how detainees are affected. However, we saw personnel stretched at times, and not able to carry out all the duties expected of them, such as offering and providing food and drinks, or arranging for detainees to shower or take exercise. Inspectors are rarely available to carry out reviews of detention at the appropriate times. Some personnel told us they felt overwhelmed.

The establishment for custody personnel consists of:

• one chief inspector responsible for the day-to-day management of custody;
• 13 inspectors;
• 110 custody officers; and
• 150 custody detention escort officers.

However, due to vacancies and sickness, at the time of our inspection only 90 custody officers and 124 detention escort officers were available for duty. Shortages are covered by overtime. Police response sergeants trained in custody cover for custody officers, and police constables cover for detention escort officers. However, the police constables have received limited training for the detention escort officer role and can’t carry out all the duties, for example fingerprinting detainees. This places additional work on the remaining detention escort officers.

The physical conditions in the six custody suites vary. Perry Barr and Oldbury are modern with good facilities but Coventry, Wolverhampton, Stechford and Bloxwich are dated and lack some facilities. All have potential ligature points. We gave the force a physical conditions report, and the force started to address some of the concerns immediately. However, many of the potential ligature points were the same ones found in the 2017 inspection, and there had been little action to mitigate the risk from them. Personnel we spoke to weren’t aware of most of the ligature points or what they should do to minimise the potential risks from them.

Initial training for staff is comprehensive and follows the nationally approved course developed by the College of Policing. All personnel have a period of shadowing and workplace assessment with more experienced staff before carrying out their duties. The force provides ongoing training five times a year with two of these days for mandatory training such as personal safety training. Other recent training has included mental health and neurodiversity awareness.

The force has adopted the College of Policing’s APP guidance. But not all personnel know the guidance or consistently follow it. For example, officers carrying out close proximity observations aren’t always briefed appropriately, handovers between shifts don’t include all personnel and clothing is routinely removed from detainees without an individual risk assessment and recorded justification.

The force isn’t consistently following PACE, its codes of practice and other legislation. This includes not clearly explaining rights and entitlements to all detainees, and not meeting requirements when reviewing detention. Girls aren’t assigned a female personnel member to oversee their care as required by the Children and Young Persons Act 1933. This is a cause of concern.

There are processes to report and investigate any adverse incidents in custody. Learning is shared at strategic meetings and through emails to personnel.

Accountability

The force collects and monitors a range of performance information. This includes:

• the number of detainees entering custody;
• average detention times;
• refused detentions;
• children;
• numbers detained under section 136 of the Mental Health Act 1983 in custody; and
• strip searches.

A monthly performance report is produced, and the information is discussed at the various force meetings described above to manage performance.

However, some important information to show how custody services perform across a wider area, such as reviews of detention, or detainee care, isn’t collected to help assess outcomes for detainees.

It isn’t clear how senior managers consistently use performance information to improve custody services. While the force identified and addressed concerns around the level of and justification for strip searching this is not the case in other areas. Concerns remain from our previous inspection, for example, how detainee risk is managed, detainee care and arranging prompt support from AAs for children and vulnerable detainees. The lack of progress and the limited management of performance to make improvements contributes to our cause of concern about leadership.

The governance and oversight of the use of force in custody isn’t good enough. Use of force is monitored at the use of powers scrutiny panels, custody governance and performance meetings. These meetings review use of force data and some review a sample of incidents from the custody record. However, the use of force isn’t always recorded on the custody record and information about incidents that is recorded isn’t always accurate. Not all staff complete use of force forms, and the quality of recording on these forms is sometimes poor. Quality assurance has recently been introduced but isn’t yet robust. In our review of 22 cases, we found that incidents weren’t always managed well. We had concerns in five cases, which we referred to the force. The force can’t assure itself or the public, that when force or restraint is used in custody, it is necessary, justified and proportionate. This hasn’t improved since our last inspection and is a cause of concern.

The quality of overall recording on custody records is often poor. We saw some detailed custody entries, but in most records important information is missing or lacking detail. For example, we found little free text in risk assessments, not enough detail explaining the reasons why a detainee’s clothing is removed, and little recording of any offers of food and drink or other care. The use of standardised pre-populated text without amendment often led to confusing, contradictory and sometimes misleading entries on custody records, especially for reviews of detention and some general cell visits.

Quality assurance arrangements to review custody records and assess how well custody services are provided aren’t robust enough and don’t cover enough areas. The force hasn’t identified some of the concerns we found during our review of records and there has been little strategic leadership to improve custody recording and quality assurance. It contributes to our cause of concern about leadership.

The force understands its responsibilities under the public sector equality duty, and provides training to help personnel understand diverse needs, for example on gender identity. The force measures a range of disproportionality data and discusses this at strategic crime governance and other senior management meetings. For example, strip searching has been monitored to identify any disproportionality, and improvements have been made in recording the ethnicity of detainees.

The force is open to external scrutiny. Independent custody visitors (ICVs) visit suites regularly and have a good working relationship with the force. They complete checklists following their visits, and any issues are dealt with at the time of the visit or at meetings between the force and the ICV scheme. The ICV scheme can access custody performance information and is involved in some custody monitoring arrangements.

Working with partners

The force works with partner organisations to provide diversion schemes and there is a priority to divert children and vulnerable adults away from custody and the criminal justice system.

The force works with youth justice services to support children and address the causes of offending behaviour. This includes work on out-of-court disposals; for example there is a deferred prosecution scheme for knife crime, which includes diversion activity. There is also some good multi-agency working with the St Giles Trust to support children in custody and when they leave.

The force regularly meets with senior managers from local authority children’s services to try and improve the arrangements for children charged and refused bail. However, despite these efforts, the lack of available alternative accommodation means few children are moved as they should be.

The force also works with mental health services at a senior manager level to try and improve support for people with mental health conditions. But the force continues to face significant challenges when dealing with people with mental health conditions. Detainees continue to wait too long in custody for assessments under section 2 of the Mental Health Act, or beds at mental health facilities, and police officers continue to have long waits at hospital with detainees until the health service takes responsibility for them.

Section 2. Pre-custody – first point of contact

Expected outcomes: Pre-custody – first point of contact

Police officers and staff actively consider alternatives to custody. They effectively identify vulnerabilities that may increase individuals’ risk of harm. They divert children and vulnerable adults away from custody when detention may not be appropriate.

Assessment and diversion at first point of contact

Frontline officers have a good understanding of how a person may be vulnerable. They told us they consider factors such as age, mental health, learning difficulties or any medical concerns as contributing towards making a person vulnerable. They also said they consider the circumstances or situation that an individual may be in, for example children who are also victims because they are involved in gangs or county line drug running. Officers take account of vulnerability when deciding whether arrest is appropriate or whether there may be better alternative ways to deal with the incident.

The force provides training on recognising and understanding vulnerability. Most officers we spoke to said they had received training, for example on mental health, the ‘voice of the child’ and domestic abuse. However, training isn’t consistent across the force area as it is mainly arranged locally. Some officers told us they would benefit from more specific training about mental health.

Frontline officers told us the information about incidents and the individuals involved provided by the call handlers in the force’s control rooms is generally satisfactory. However, the quality and timeliness of the information varies and on occasion doesn’t equip officers well enough to help them deal with incidents. As a result, sergeants sometimes get involved in finding out more information and officers can also get information about incidents and individuals from their mobile devices. Officers told us they felt that they generally had enough information to help decide what action to take.

Children are only arrested when all other alternatives have been explored. Frontline officers consider whether the matter can be dealt with by other means. These include:

• voluntary attendance interviews;
• community resolutions;
• discussing incidents with the child and their parents to find a solution and suggesting agencies who may be able to help with any support for their needs or behaviour; or
• involving designated police school officers in working with the child.

However, officers also consider safeguarding the child and others, and the severity of the offence, when deciding what action to take. Sometimes these factors leave no choice other than to arrest.

Frontline officers have little direct involvement with youth offending teams or other support agencies to allow diversion before arrest. However, they told us this support is available in and after custody to support children to try and prevent them from further offending and from entering the criminal justice system.

A team of police officers trained in mental health provides support to frontline officers attending incidents involving people with mental health conditions. The team provides advice and assistance and liaises with mental health services to find out information about individuals. This helps officers decide what to do, what alternative health options may be available, and which health facility people detained under section 136 of the Mental Health Act 1983 should be taken to. However, the team isn’t available 24 hours a day and, outside its working hours or if the team is busy on other calls, the officers at the scene are left to make their own decisions, including whether to detain someone under section 136.

Frontline officers told us that they normally take people detained under section 136 to hospital A&E departments as there are rarely places available at the mental health facilities. Although this varies across the force area, officers told us this usually involves long waits with the person before they can be transferred to the care of the health service.

Overall, the arrangements between the force and mental health services to help people in mental health crises aren’t working well enough, with poor outcomes for the person in mental health crisis and poor use of police time.

Where a person has committed an offence, officers arrest and take them to custody, unless it is clear they are in mental health crisis. Once in custody the investigation continues, alongside dealing with any mental health concerns. However, officers told us they are called to take detainees to hospital because they have been detained under section 136 so that they can be transferred from custody to a health facility.

Officers transport detainees in police cars or caged vans depending on the risks the detainee poses. Ambulances are called to transport people detained under section 136 to hospital but there can be long waits, so officers seek authority from an inspector to use police vehicles. We were told that people with mobility difficulties or who used wheelchairs would normally be transferred in the vans as these were large enough to accommodate most needs.

Section 3. In the custody suite – booking‑in, individual needs and legal rights

Expected outcomes: In the custody suite – booking‑in, individual needs and legal rights

Detainees are treated respectfully in the custody suite and their individual needs are identified and met. Detainees’ risks are identified at the earliest opportunity and managed effectively. Detention is appropriately authorised. Detainees are informed of their legal rights and can freely exercise these rights while in custody.

Respect

Custody staff interact respectfully with detainees and are patient and reassuring. But due to the design of some of the suites, if more than one detainee is dealt with at the same time, the environment can be noisy and other detainees can overhear sensitive conversations. Some suites have discrete booking-in desks for use in vulnerable and sensitive cases, but we found they often weren’t used. Custody officers don’t routinely offer detainees the opportunity to speak to a member of staff in private during booking-in.

The suites’ communal areas and some cells are covered by CCTV, and there are notices in the suites saying this. But staff don’t always tell detainees about it, or that the toilet area in cells is obscured from the cameras. The positioning of CCTV monitors in all the suites other than Coventry and Wolverhampton means they can be seen by non-custody personnel. This could compromise detainees’ privacy.

Not all shower areas offer detainees enough privacy as the doors are too low, and they can be seen from corridors.

Detainees are given suitable replacement clothing if their own is removed and plimsolls as replacement footwear to wear in the cell. But when staff remove detainees’ clothing for safety reasons, some detainees don’t then put on the safety clothing they are given as a replacement. And they aren’t always encouraged to do so, which means some remain naked in cells.

Meeting diverse and individual needs

Custody staff recognise and do their best to meet detainees’ individual and diverse needs. But facilities in the suites sometimes make this difficult. There are few adjustments for detainees with physical, hearing or visual impairments. For example:

• Wolverhampton and Coventry don’t have wheelchairs and the one at Perry Barr is in poor condition.
• There are no extra thick mattresses.
• Wolverhampton, Bloxwich and Coventry don’t have sight lines in any of the cells (markings to help visually impaired people to judge the position of walls and obstructions).
• There are no ‘Easy Read’ or Braille versions of rights and entitlements leaflets in the suites, or custody personnel don’t know where these are kept.
• Wolverhampton and Oldbury don’t have hearing loops.
• Not all suites have adapted toilets.

The force could meet the needs of women better. Women aren’t allocated a female officer to speak with or meet their care needs. There is a good stock of menstrual products in all suites, but not enough attention is paid to handwashing facilities when there are no sinks in cells.

Custody staff generally understand the needs of neurodivergent detainees and how they may be affected by the custody environment. There are distraction activities to help these detainees, but they aren’t routinely offered to them or children and others who could benefit from them.

Detainees aren’t routinely asked at booking-in if they have caring responsibilities for others or if they want to speak to an officer of the same sex in private.

Detainees aren’t always asked their ethnicity, and the process is hindered because there are no printed lists of ethnic groups for them to refer to.

Most personnel we spoke to had a good awareness of how to respectfully meet the needs of transgender detainees.

The religious items to help detainees observe their faith are reasonable. The suites cater for Islam, Christianity, Hinduism, Sikhism and Judaism with items stored in their own boxes, apart from Bloxwich, which has them all in one box. However, custody personnel’s understanding of how religious texts should be stored and treated could be better and some were in a poor state of repair.

Provision for detainees who speak little or no English is reasonable. Interpretation is available for most languages. Conversations take place at the counter over a loudspeaker, which means there is little privacy, and communication is hampered by poor acoustics, COVID-19 screens and no three-way phones. This hasn’t improved since our previous inspection.

Risk assessments

The force’s identification of detainee risks is generally good, but they aren’t always managed well enough and APP guidance isn’t always followed. There has been little improvement since our last inspection. Risk management is a cause of concern.

Detainees aren’t always booked into the custody suites promptly. When queues occur, these aren’t managed well and custody personnel don’t prioritise children, vulnerable adults or detainees presenting greater risk for booking-in.

Custody officers generally carry out initial risk assessments with the detainee well. They check previous warning markers on the police national computer and other information that might help their assessment. They also ask the arresting officers if they have any information relevant to the detainee to help manage the risks. But they don’t always explain the purpose of the risk assessment well enough to detainees and why they need to ask personal questions and record the details.

When detention escort officers book detainees into custody we found the risk assessments by the less experienced officers weren’t always thorough enough. The detainee’s answers to the risk questions were accepted without further probing to obtain more information on which to base their decisions. Custody officers were often busy booking in other detainees and unable to provide guidance or oversee the process.

The level of observations required is usually set at the level commensurate with the risks. Detainees under the influence of alcohol and/or drugs are placed on level 2 observations with rousing every 30 minutes. However, on occasion, we found these detainees placed on level 3 observations (constant CCTV observations) without being roused as required. This poses potential risks.

Most detainees on level 2 checks are usually roused in the right way and at the right time. This is recorded correctly in the custody record. In most cases, the same detention escort officer completes the checks. This is important as it makes it easier to establish changes in a detainee’s behaviour or condition when under the influence of alcohol or drugs. But some police officers we spoke to who were covering the detention escort officer role didn’t have enough knowledge about the different levels of observations and what was required of them.

When detainees are placed on level 1 checks (which don’t involve rousing the detainee), these are carried out on time and appropriately through an open hatch. But many of the entries we saw on custody records were generic with little or no bespoke detail about the individual detainee.

When detainees are assessed as high-risk, they are placed on level 4 (close proximity) observations, but these aren’t always carried out well enough. The officers responsible for the observations aren’t always briefed by the custody officer about the risks the detainee poses, the detail of the briefing isn’t recorded on the custody record, and the observing officers don’t always keep a log of their observations for the custody record. Similarly, detention escort officers carrying out level 3 observations (constant monitoring of the detainee on CCTV) aren’t always briefed by custody officers regarding the specific risks of the detainee. These practices don’t follow APP guidance or the requirements of PACE Code C, paragraph 3.8.

Custody officers periodically review the observation levels and change them if needed, recording the reasons why.

Custody personnel routinely remove footwear and clothing with cords, rather than justifying this through an individual risk assessment and clearly recording the reasons why the removal is necessary. This is a poor outcome for detainees, who are often made to change their clothing or, in some cases, have their clothing removed by force, which further escalates any risk. This practice doesn’t follow APP guidance.

The anti-rip clothing, used to replace detainees’ own clothing because of safety concerns, consists of a short-sleeved top and bottoms, made of paper-type material. However, this isn’t always used, as custody officers informed us that if it gets wet, it can easily be torn and used as potential ligatures.

Handovers aren’t carried out collectively between the incoming and outgoing custody personnel, and they don’t include HCPs or L&D staff. This fails to make sure all relevant information is shared among those taking over responsibility for detainees. In some custody suites handovers are carried out in areas where there is limited video or audio coverage. After handovers, custody officers don’t visit and interact with the detainees they have accepted responsibility for. Instead, this is carried out by detention escort officers. These practices don’t follow APP guidance.

Cell call bells are audible and are responded to appropriately by custody personnel. They can be muted but only after discussion between the detention escort officer and the custody officer. The call bells have to be manually turned back on, other than at Perry Barr and Oldbury where this happens automatically.

Custody personnel we saw and spoke to had personal-issue anti-ligature knives, which they carry while on duty. This means they can respond to potential self-harm incidents without delay.

The control and management of cell keys is good. Custody personnel use a booking‑in and out sheet, which records who has taken the keys. The keys are stored behind the booking-in areas.

Individual legal rights – detention

Waiting times for detainees to be booked into custody varies. Some are booked in promptly, but we found others waiting over an hour, and some detainees waited more than three hours, including some children. There is little or no prioritisation of children or detainees who are vulnerable or pose more risks.

Arresting officers generally provide the circumstances surrounding the arrest well. But they don’t always explain the grounds for the necessity of an arrest well enough to allow the custody officer to make their independent decision on whether to authorise detention. Custody officers don’t always ask for further information to satisfy themselves that it is necessary to detain.

Refusals of detention are closely scrutinised by senior managers to make sure they are appropriate. Some custody officers told us this deterred them from asking for further information about the necessity to detain as they felt they would be criticised for this, and any decision to refuse detention wouldn’t be supported. However, we observed some detentions authorised without enough information to make a robust decision. In our view, detention should have been refused on some occasions.

Voluntary attendance is used as an alternative to taking a person into custody. Police stations have interview rooms to use for voluntary attendees, so they only enter custody for fingerprinting or other custody processes.

Some detainees spend longer than necessary in custody as cases aren’t always dealt with expeditiously. Investigators aren’t available 24 hours a day, and some detainees wait for the next shift to come on duty before they are dealt with. We found some detainees were waiting a long time before they were interviewed when few other enquiries were needed. Some detainees brought to custody in relation to previous incidents had outstanding case enquiries, which should have been dealt with prior to them arriving to keep their time in custody to a minimum. Custody officers and reviewing inspectors aren’t given the information detailing the further enquires to be carried out, so they need to chase investigators for updates. But they don’t always have time to do this.

The force monitors detention times but it isn’t clear how it uses this information to assess if cases are dealt with as quickly as possible and the reasons for any delays.

Bail is appropriately authorised for detainees released pending further enquiries. However, bail conditions aren’t always appropriate or reasonable for a detainee to adhere to, for example not clearly defining distances or areas that the detainee is required to avoid.

Custody personnel told us there are good working relationships with immigration services to move detainees from custody to immigration detention facilities. According to information provided by the force for the year 1 April 2022 to 31 March 2023, immigration detainees spent an average of 25 hours in custody overall, 15 of which were after the service of their immigration papers (IS91).

Individual legal rights – detainees’ rights and entitlements

Detainees should be told about their rights and entitlements in custody. These include:

• to have someone informed of their arrest;
• to consult a solicitor and access free independent legal advice; and
• to consult the PACE codes of practice.

However, custody officers don’t always explain the rights and entitlements to detainees well enough. We saw some custody officers taking time to explain them fully to the detainee and making sure they understood them, but this doesn’t happen routinely.

PACE Code C booklets aren’t routinely offered to detainees and there aren’t enough copies in the suites – some suites had only one booklet. Custody officers offer the rights and entitlements leaflet but tell detainees this is an abridged copy of the booklet, which is misleading for the detainee. They should be offered both.

There is no ‘Easy Read’ version of rights and entitlements leaflets for children and those who need help in understanding their rights in any of the suites.

There are no posters in any suites explaining legal rights in different languages (as required by PACE Code C, paragraph 6.3). Some suites display printed sheets on the wall, but these aren’t prominent and are difficult to read.

Custody officers don’t always explore with detainees why they refuse legal representation, and don’t record the reasons for its refusal.

There are enough interview and consultation rooms for detainees to consult privately with their legal representative. Legal representatives usually attend in person and can see the custody record of their client on request.

Custody officers understand Annex M PACE Code C, which states that detainees should receive documents and records on important information about custody processes in a language they can understand. During the inspection we saw rights and entitlements information printed and handed to detainees in their own language.

Detainees who are foreign nationals have the right to speak to somebody at their country’s embassy, consulate or high commission at any time. Custody officers arrange this if requested. When custody officers are required to notify these bodies because an agreement exists with the relevant country, this is done.

When detainees are held incommunicado (delaying their right to have someone informed of their arrest) this is appropriately authorised, and removed when no longer required.

The force retention and disposal policies for DNA, fingerprints and custody images aren’t explained to detainees. Nor are there any posters explaining this process in the custody suites. Not all suites securely store DNA in a freezer that is either locked or in a locked room, affecting the integrity of the samples. The samples are collected regularly from all suites.

Reviews of detention

Reviews of detention don’t always comply with the requirements of the PACE codes of practice. They aren’t carried out well enough, or in the best interests of the detainee. They contribute to our cause of concern for meeting legal requirements.

We found reviewing inspectors lacked understanding of the role, and we were told they had received little or no training.

Inspectors don’t usually have time to carry out reviews at the required time or in a satisfactory manner. We found inspectors regularly conducted 28 to 35 reviews during their shift across the 3 sites.

Reviews are often conducted either early or late. They are usually carried out in person by inspectors at Perry Barr and Oldbury but often by telephone at the other suites. We were told this is the only way of getting all the reviews done at these suites. There is no additional consideration as to how reviews are conducted for children and vulnerable detainees, as required by Code C, paragraph 15.3C.

When reviews are carried out by telephone, inspectors don’t explain well enough why they didn’t attend in person, as required by Code C, paragraph 15.14.

When reviews are carried out while the detainee is asleep, they aren’t routinely reminded of this at the earliest opportunity as required by PACE Code C, paragraph 15.7.

Further detention is sometimes authorised prior to the detainee being given any opportunity to make representations, and in some reviews we observed not authorised at all.

Reviewing inspectors rarely speak to investigators regarding the progress of the investigation. They rely on updates on the custody record that an investigator has been allocated and accept that the investigation is being progressed. They authorise further detention based on this rather than satisfying themselves that it is necessary.

Reviews included little focus on the welfare needs of detainees, although inspectors offered detainees food and drink.

Complaints

The complaints process isn’t displayed for detainees to see. There are no notices in any suites explaining how detainees can make a complaint, and no leaflets from the Independent Office for Police Conduct with information about how to complain to them.

Although staff know that complaints from detainees should be taken while they are in custody, few could give examples of where this had occurred. We were told it was difficult to get an inspector to take complaints from detainees while they were still in custody. Instead, detainees are directed to the West Midlands Police website.

Section 4. In the custody cell – safeguarding and healthcare

Expected outcomes: In the custody cell – safeguarding and healthcare

Detainees are held in a safe and clean environment, which protects their safety during custody. If force is used on a detainee this is as a last resort. Their care needs are met, and children and vulnerable adults are protected from harm. They have their physical and mental health, and any substance misuse, needs met.

Physical environment

West Midlands Police has six designated custody suites at Perry Barr, Oldbury, Coventry, Wolverhampton, Stechford and Bloxwich. The force owns the buildings housing the suites and employs its own cleaning and maintenance staff. Stechford and Bloxwich were previously closed, but re-opened on 2 May 2023 to align custody better with local policing areas and help accommodate increasing numbers of detainees.

There are potential ligature points in all the suites, mainly due to the design of toilets and the water outlet holes, areas around benches in cells, the fitting of some cell doors, and in the shower areas and exercise yards. We found custody personnel had limited knowledge of these, so little action has been taken to mitigate the risks from these. During the inspection we gave the force a comprehensive illustrative report detailing these and the physical conditions in the suites more generally.

Cleanliness across the suites is generally good. But the cell floors in some suites, especially Stechford and Wolverhampton, are dirty, particularly around toilets. Staff couldn’t tell us how often deep cleaning of suites takes place, or if there is a programme for this. There is little graffiti in cells. We were told repairs are mostly completed quickly.

The ventilation and temperature in the suites and individual cells are satisfactory and there is natural light in nearly all cells. Several cells designated for children don’t have natural light or any toilets and, in our view, aren’t suitable for any detainee, especially not for children.

All cells at Perry Barr and Oldbury have toilets and sinks for handwashing. But the other suites only have toilets in them, with communal sinks on the cell wings.

There are discrete booking-in areas at Perry Barr, Oldbury and Wolverhampton but no arrangements at the others. Perry Barr, Oldbury and Wolverhampton also have some glass-fronted cells to aid those who experience claustrophobia. Most holding areas for detainees are multi-occupancy rooms, which are used frequently to avoid detainees waiting outside custody suites in vehicles.

Custody staff told us they carry out a daily walkthrough of the suite to check conditions. But these don’t include checking for ligature points. More comprehensive weekly checks of cells and facilities are also carried out and a checklist completed and emailed to the inspector. However, we found many of the daily and weekly records of these checks were missing, although there had been a recent improvement in their completion.

CCTV operates in the suites’ communal areas and in about half of the cells. The CCTV viewing arrangements for observing detainees in their cells are good at Perry Barr and Oldbury. But at the other suites, personnel sit in small, cramped spaces in the staff refreshment room where they can be distracted from their observations. The arrangements are also hindered by the quality of the images, which is generally poor.

There are signs advising detainees that CCTV is operating but the number varies between suites. In some, the signs aren’t always in places where detainees can easily see them, such as the booking-in desk areas.

Most personnel understand emergency evacuation procedures but not all of them have been involved in fire evacuation drills. There has been some training, but staff knowledge of these important procedures varies.

There are enough handcuffs in the suites to manage an evacuation, but there aren’t tabards at all suites or torches at any of them. There is no central storage (such as bags) where they are kept and can be easily accessed. One suite had handcuffs in a biscuit tin and in another, the handcuffs were still in their original boxes on a shelf.

Use of force

When force is used in custody some incidents aren’t managed well and it isn’t always recorded in enough detail. This makes it difficult for West Midlands Police to show that when force is used in custody it is necessary, justified and proportionate. It is a cause of concern.

We reviewed 22 cases of use of force on CCTV. When force was used, in most cases it was proportionate to the risk or threat posed. We also saw some good communication and negotiation by officers, which de-escalated situations well and avoided the need to use force.

But incidents aren’t always managed well. Custody officers sometimes become involved in the use of force and don’t always oversee and direct the use of force incident well enough.

Restraint techniques weren’t always deployed safely and sometimes officers failed to appropriately control the situation. This resulted in the incident escalating and further force being used, increasing the risk of injury to the detainee and the officers involved.

In some of the cases we reviewed, force was used to remove a detainee’s clothing or other items. It wasn’t always clear from custody records, or our observations on CCTV, that the removal was necessary and justified. In our view, it led to using force that could potentially have been avoided. In addition, officers didn’t always maintain the detainee’s dignity well when removing the clothing.

We referred five cases to the force for learning. These included how the dignity of the detainee was considered, the use of techniques that, in our view, could have resulted in injury to the detainee, and how the detainee’s risks had been appropriately assessed and managed.

Officers who use force on detainees in custody don’t always submit individual use of force forms as required by National Police Chiefs’ Council guidance. We asked for use of force forms for the incidents we reviewed but received no forms for some cases, and in many of the others we didn’t receive all the forms we were expecting.

Use of force incidents aren’t always included on the custody record. When use of force is recorded the details are sometimes limited.

The force has introduced quality assurance for use of force in custody. Inspectors review a sample of cases by looking at the custody record, CCTV and, if available, body-worn camera footage.

However, the inspectors only select incidents from the custody record, so they only review those that have been recorded. Use of force forms aren’t used to allow a more robust sample to be selected or to assess any under-recording of the use of force in custody. The quality assurance hasn’t identified some of the concerns we are raising, so it isn’t clear how effective these arrangements are.

Handcuffs aren’t always removed quickly enough from compliant detainees. The reasons why handcuffs are used are usually recorded but the time they are removed isn’t.

The force has taken action to understand the high number of strip searches taking place in custody. Decisions and the justification for strip searches are closely scrutinised and the number is reducing. However, we found that the necessity and justification for a strip search weren’t always clearly recorded on custody records.

Strip searches were generally managed well but the dignity of the detainee wasn’t always considered when conducting them.

Most custody officers and all custody detention officers are up to date with their officer safety training. For those who aren’t up to date there are no specific plans to address this.

Detainee care

The approach to detainee care is mixed. Staff have a caring attitude and the detainees we spoke to were positive about the care given to them in custody. But detainees aren’t always advised of the care provision available to them when they are booked into custody, such as showers, exercise or reading material.

The range of food and drink is good and meets most dietary requirements, although some foods aren’t re-stocked quickly enough. We observed that food and drink was offered to detainees, but not always as often as it should be, and staff didn’t always record on the custody record when it was offered or provided. We found little effort was made to encourage detainees who hadn’t had food for some time to eat. There is no dietary guidance displayed in the kitchens.

Distraction materials such as foam balls, colouring books and fidget poppers are available in all suites except Bloxwich. We didn’t see them offered routinely and some suites had run out of foam balls as they allowed the detainees to take them home.

The range of reading material is reasonable, but there aren’t enough books for children in the suites. And only Bloxwich had foreign titles, and these are only in Urdu. There are no set arrangements to re-stock reading material.

Showers and exercise aren’t routinely offered and, when detainees request them, custody personnel can’t always provide these because they are too busy. All suites have exercise yards, but not all have a covered area for exercise during bad weather. Detainees on exercise are monitored by a member of the custody team.

Toilet paper is provided to detainees on going to the cell in all suites, except Coventry where detainees must ask for it. None of the suites have shaving facilities.

There is a good supply of replacement clothing in a range of sizes with underwear for both sexes.

The quality, cleanliness and condition of the mattresses are generally poor with some mattresses providing little support. They are often folded when not in use, which has damaged them. None of the suites have extra thick mattresses. Pillows are provided as standard.

There are safety blankets (which can’t be easily ripped) and warmer blankets available. However, these aren’t routinely given to detainees on entering the cell, so detainees must ask for them.

Safeguarding children and vulnerable people

Custody officers and detention escort officers receive training to raise their awareness, knowledge and understanding of vulnerability. Additional guidance and support are also available online via the force’s intranet site.

There are robust arrangements to safeguard detained children. Arresting and investigating officers make referrals to local youth offending teams to assess children’s support needs and to consider the disposal and other options to prevent further offending.

All children in custody are assessed by a healthcare practitioner – although this arrangement is currently under review – and are also referred to L&D services. This offers additional opportunities to identify and address any safeguarding concerns, as well as any additional support needed after their release. Women and vulnerable detainees are also referred to L&D for assessment. However, limited L&D staffing means these assessments don’t always happen.

Girls held in custody are required to have a same-sex member of staff assigned to safeguard and monitor their welfare while in custody as required by the Children’s and Young Persons Act 1933. However, in the cases we examined, this hadn’t happened, which is poor. Custody managers have recently included scrutiny of this as part of their quality assurance of custody records to improve the position.

Appropriate adults

Children and vulnerable adults don’t always receive support from AAs quickly enough.

Parents, other family members or carers are considered to act as AAs in the first instance. Where they aren’t available, or can’t act as the AA, the force has arrangements with the local authorities’ children services for children, and the Office of the Police and Crime Commissioner volunteer scheme for vulnerable adults. However, these arrangements don’t always result in AAs arriving promptly.

Custody officers contact AAs for children as soon as possible after their arrival in custody. However, there are sometimes long delays before AAs attend custody to help children understand their rights and entitlements and safeguard their interests. In some of the cases we examined AAs didn’t arrive until just before the interview. When children were arrested late in the evening or at night, custody officers didn’t always arrange for the AA to come in as soon as possible, but instead asked them to attend the following day.

Custody officers don’t always give enough consideration to whether a vulnerable detainee needs support from an AA. We examined and observed some cases where the need for an AA was identified early in the person’s detention. But in other cases, this wasn’t identified despite the detainee disclosing mental health conditions, learning disabilities or other indicators of vulnerability during the initial risk assessment. In some cases, it was our view an AA should have been requested. HCPs sometimes identified that an AA was needed during their interactions with the detainee, but this could be several hours into detention.

The role of the AA isn’t always sufficiently explained to either the AA or the detainee, and we didn’t see any AA guidance leaflets given to either of them.

The recording of AA contact and arrival times, and of the relationship of the AA to the detainee, is limited and often confusing. This makes it difficult for the force to assess how well it is meeting detainee needs.

Prompt AA support for children and vulnerable adults and poor record keeping were concerns in our previous inspection. There has been little improvement.

Children

There is a good focus among frontline and senior officers, as well as custody personnel, on diverting children away from custody where possible. Custody officers only authorise their detention after other options have been considered. In the cases we examined, the children had been involved in serious crimes requiring arrest and detention.

Children who are arrested are generally taken to one of the larger suites at Perry Barr or Oldbury. These suites cater better for children, with discrete booking-in facilities to provide greater privacy on arrival and dedicated ‘juvenile’ cell corridors, which include pictures on the walls to improve the environment. However, following recent operational changes, we found the cells in the ‘juvenile’ corridor were no longer being used exclusively for children.

Perry Barr and Oldbury also offer additional support for children by having St Giles Trust workers in the suites who visit children and provide support for them.

Other than the facilities at Perry Barr and Oldbury there were no arrangements to meet children’s additional needs or mitigate the effect of custody on them. While there is a generally good supply of ‘distraction’ items (such as colouring in materials, stress toys and soft balls) to help children, and any others who may benefit from them, we didn’t see these routinely offered or provided. Children spend little time out of their cells, for example in the exercise yards or sitting in other areas of custody such as a consultation room with a family member, even when they are held for long periods.

Some children spend a long time in custody. We found little focus on dealing with their case or releasing them on bail or under investigation to try and keep their time in custody as short as possible. There are also some delays waiting for AAs to arrive. Inspectors reviewing a child’s detention didn’t assess if the case was being dealt with as quickly as possible or consider alternatives if progress was likely to be slow.

There are arrangements to monitor the detention of, and outcomes for, detained children. Children are routinely considered at both custody and senior manager performance meetings. They are also considered at Office of the Police and Crime Commissioner-led performance meetings. A multi-agency forum examines how children are diverted away from the criminal justice system. The force also meets at a strategic level with the local authorities’ children’s services to discuss children remanded in custody, and the requirement for alternative accommodation.

When children are charged and remanded into custody, they should be moved to alternative accommodation arranged through the local authority while they are waiting to appear in court. Despite the force’s efforts and work with partners to improve the provision of alternative accommodation, there has been little progress since our last inspection. Although the force requests alternative accommodation, few children are moved.

In the year up to 31 March 2023, information provided by the force shows 162 children were remanded. Of these, only 12 of 121 requests for alternative accommodation (both secure and ‘appropriate’) resulted in the child being moved. In some of the cases we examined where secure beds were required, bed requests to local authorities were made but these often occurred late at night when earlier conversations might have helped. Custody officers complete juvenile detention certificates but neither these nor custody records showed whether the cases had been escalated to the duty inspector or other senior officers.

Healthcare

Mountain Healthcare Limited provides physical healthcare support to detainees. HCPs are based in all custody suites around the clock. The team are well staffed and shift rotas allow cover for absences when needed. The force monitors the contract through monthly performance and contract meetings.

There is good joint working between the force and Mountain Healthcare Limited, with robust governance arrangements to monitor the safety and quality of care provided to detainees. Governance systems include regular audits by practitioners and clinical leads to monitor and improve the quality and safety of care provided.

There are appropriate information-sharing agreements between health partners and the force. However, HCPs can’t always access community mental health or summary care records promptly to obtain information about detainees in custody.

Healthcare staff receive relevant training including safeguarding to recognise and manage detainees’ vulnerabilities. They have annual appraisals of their performance, and all staff have access to regular managerial and clinical supervision. They told us they felt well supported in their roles.

Medical rooms are cleaned daily, and temperatures are monitored to maintain the integrity of medicines stored in the room. However, four of the six custody suites are small and don’t meet infection control guidelines. Not all rooms contain the required equipment, and rooms require decoration and renovation to meet appropriate standards. Emergency equipment including oxygen is available in each room and checked daily by clinical staff. HCPs have access to automated external defibrillators.

Healthcare staff arrange interpreters for detainees whose first language isn’t English.

Incidents are reported online and are investigated by managers. Learning from incidents is shared with staff during team meetings, supervision forums and daily briefings.

Health providers have a confidential complaints process, but this isn’t advertised to detainees in all custody suites.

Physical health

Detainees receive prompt clinical assessment and treatment from experienced and competent practitioners. Staff we spoke with were knowledgeable and compassionate about their role in helping detainees, and custody staff were positive about the interactions they had with HCPs.

HCPs request consent from detainees to carry out assessments of physical and mental health (including their mental capacity), substance misuse, social care and safeguarding. Clinical assessments are recorded on the provider’s electronic system, and a summary, including risk information and recommendations, is recorded on the custody detention log. HCPs contribute to decisions regarding risk, fitness to detain, and interview.

HCPs individually risk assess whether they see a detainee in private with the door closed, or whether it would be safer to have a custody staff member close by. However, there are no privacy curtains or screens in any medical rooms to protect detainees’ dignity during clinical examinations, which is poor.

Mental health

Three different NHS healthcare trusts provide differing models of L&D to support detainees with vulnerabilities in custody. Contracts are monitored by NHS England commissioners. However, the L&D services and staffing levels vary across custody suites, resulting in an inequitable service to detainees across the force area.

The L&D providers, except for the provider serving Coventry, don’t have enough staff to work from all of the custody suites on a regular basis. When they can’t attend a suite in person, practitioners offer a telephone advice and remote screening service instead. They can’t see all women and children as required under the contracts, and the arrangements for referring vulnerable detainees, such as veterans, for further support are underdeveloped.

In Coventry there is a rich skill mix in the L&D team including a speech and language therapist and specialist support for those with learning disabilities. This means detainees in this suite receive a good level of service.

Custody officers refer detainees to L&D services electronically, although in some areas they are also asked to make a paper referral, which duplicates the information. Referrals are prioritised for detainees with greatest risk or need. When L&D teams see detainees, they provide a good standard of assessment and make referrals for support on release.

Custody staff have good relationships with L&D in some suites, but in others, relationships are strained because there aren’t enough L&D staff to provide the service required. The absence of L&D staff in some areas also increases the workload of HCPs.

Practitioners can refer detainees to support, time and recovery workers and peer support workers (both roles are part of the L&D service) to support detainees in the community after leaving custody. These workers encourage people to engage with support services on their release to break their cycle of reoffending.

Clinical records are held on each trust’s electronic record system. However, not all L&D teams have access to custody records so they can record information on the detention log about their interventions with the detainee. Information is given orally, but this risks not all staff being aware of the detainee’s risk or plan of care.

Custody isn’t used as a place of safety under section 136 of the Mental Health Act 1983. However, there are often long delays for section 2 Mental Health Act assessment, so if the detainee is at risk of serious harm, custody officers use section 136 to move the detainee out of custody to a hospital or mental health facility. The force monitors its use of section 136.

Police officers have access to a telephone advice line to obtain mental health advice and information when dealing with incidents in a public place involving people with mental health conditions. However, this operates a limited-hours service. There is no street triage service available across the force area.

The force is working with mental health services to try and improve services for people with mental health conditions coming to the attention of police or detained in custody. But outcomes for these people remain poor.

Substance misuse

Support for detainees with substance misuse needs is good. Substance misuse practitioners attend all custody suites daily to see the necessary detainees for the required assessment under the drug test on arrest scheme, as well as offering a voluntary assessment to other detainees in custody. Practitioners also leave information for custody officers to give detainees on release from custody.

As part of the substance misuse service for detainees in custody, the force can refer detainees for treatment under the conditional caution scheme.

Practitioners liaise with community substance misuse teams and can refer detainees to services if they aren’t already receiving treatment.

HCPs assess and provide treatment for detainees withdrawing from drugs and alcohol while in custody. They use nationally recognised clinical tools to inform their decision-making and monitor detainees’ treatment needs while in custody. When clinically indicated, staff administer medicines to relieve symptoms of withdrawal.

Under the healthcare provider’s policy, HCPs aren’t permitted to issue detainees with their prescribed opiate substitution medication at the required time, which potentially places them at risk when they are released from custody. Instead, HCPs are only able to offer symptomatic relief.

Medicines management

Medicines are stored appropriately and administered to detainees in line with national guidance. The provider has patient group directions to support staff with decision-making on health issues such as asthma, pain and acute withdrawal from alcohol and drugs.

Nicotine replacement therapy isn’t offered to detainees by custody personnel or the health provider, which is poor.

There are good governance arrangements to manage medicines safely. Medicines, including controlled drugs, are stored safely and subject to daily audits and stock checks. Custody personnel store detainees’ own labelled medicines securely in the detainees’ property locker, and HCPs assess the detainee before administering any of their own medicines.

Staff report medicine errors through the electronic reporting system and investigate these promptly.

Section 5. Release and transfer from custody

Expected outcomes: Release and transfer from custody

Detainees are released or transferred from custody safely. Those due to appear in court in person or by video do so promptly.

Safe release and transfer arrangements

Custody officers carry out pre-release risk assessments with the detainee present. However, these aren’t always thorough enough. They are mainly based on a set of pre-release questions with yes or no answers, with limited reference to the initial risk assessment or concerns that may have arisen during custody. This means some risks may not be considered or discussed with the detainee before they are released. This contributes to our cause of concern regarding how detainee risks are managed.

Leaflets with information about details of agencies offering support to detainees aren’t available at all the custody suites (although they are held on the force’s computer system for printing off). They aren’t always given to detainees when they are released.

When detainees are released on bail, custody officers explain what this means. But they don’t always explain bail conditions well enough. Those released under investigation are informed of the possible offences they may commit if they interfere with victims or witnesses while the investigation is ongoing. Written information is also given.

Most detainees released from custody are required to make their own transport arrangements to get home safely. There are travel passes at some suites, but these aren’t always considered as an option. The arrangements aren’t always clearly recorded on the custody record to show how detainees are getting home.

The detention escort officers on the night shift complete the digital person escort records for detainees transferring to court or back to prison the following day. We found these were completed well, identifying any risks or health concerns and including medical information. But the custody officer responsible for releasing the detainee doesn’t always check or sign off these forms, as required by APP guidance. Where detainees were required for court or prison during the day, we saw some good examples of custody officers completing handwritten person escort records and overseeing the release process.

Courts

Detainees appear before the local court in person and are dressed appropriately. They are generally transferred promptly to the next available court. This keeps their time in custody to a minimum.

Custody personnel ask the relevant courts if they will accept detainees who have been arrested or remanded after the morning collection by the escort agency so they don’t spend longer than necessary in police custody. If the courts accept them, police officers usually take them there promptly.

We were told the courts have different times for accepting detainees later in the day. If they are full, detainees remain in custody overnight or until the next available court space.

Section 6. Summary of causes of concern, recommendations and areas for improvement

Causes of concern and recommendations

Areas for improvement

First point of contact

In the custody suite – booking-in, individual needs and legal rights

In the custody cell – safeguarding and healthcare

Release and transfer from custody

Section 7. Appendices

Appendix I – Methodology

Police custody inspections focus on the experience of, and outcomes for, detainees from their first point of contact with the police and throughout their time in custody to their release. We visit the force over two weeks. Our methodology includes the following elements, which inform our assessments against the criteria set out in our Expectations for police custody.

Document review

Forces are asked to provide various important documents for us to review. These include:

• the custody policy and/or any supporting policies, such as the use of force;
• health provision policies;
• joint protocols with local authorities;
• staff training information, including officer safety training;
• minutes of any strategic and operational meetings for custody;
• partnership meeting minutes;
• equality action plans;
• complaints relating to custody in the six months before the inspection; and
• performance management information.

We also request important documents, including performance data, from commissioners and providers of health services in the custody suites and providers of in-reach health services in custody suites, such as crisis mental health and substance misuse services.

Data review

Forces are asked to complete a data collection template based on police custody data for the previous 36 months. The template requests a range of information, including:

• custody population and throughput;
• the number of voluntary attendees;
• the average time in detention;
• children; and
• detainees with mental health problems.

This information is analysed and used to provide background information and to help assess how well the force performs against some main areas of activity.

Custody record analysis

We analyse a sample of custody records drawn from all detainees entering custody over a one-week period prior to the start of our inspection. The records are stratified to reflect throughput at each custody suite and are then picked at random. Our analysis focuses on the legal rights and treatment and conditions of the detainee.

Case audits

We audit around 40 case records in detail (the number may increase depending on the size and throughput of the force inspected). We do this to assess how well the force manages vulnerable detainees and specific elements of the custody process. These include examining records for children, individuals with mental health problems, those under the influence of drugs and/or alcohol, and cases where force has been used on a detainee.

Our audits examine a range of factors to assess how well detainees are treated and cared for in custody. Audits examine, for example, the quality of risk assessments, whether observation levels are met, the quality and timing of PACE reviews, whether children and vulnerable adults get support from appropriate adults when they need it, and whether detainees are released safely. We also assess whether force used against a detainee is proportionate and justified, and is properly recorded.

Observations in custody suites

Inspectors spend a significant amount of their time during the inspection in custody suites assessing their physical conditions, observing operational practices, and assessing how detainees are treated. We speak directly to operational custody officers and staff, and to detainees to hear their experience first-hand. We also speak to other non-custody police officers, solicitors, health professionals and other visitors to custody to get their views on how custody services operate. We examine custody records and other relevant documents held in the custody suite to assess how detainees are dealt with, and whether policies and procedures are followed.

Interviews with personnel

During the inspection we interview officers from the force. These include:

• chief officers responsible for custody;
• custody inspectors; and
• officers with lead responsibility for areas such as mental health or equality and diversity.

We speak to people involved in commissioning and running health, substance misuse and mental health services in the suites and in relevant community services, such as local Mental Health Act section 136 suites. We also speak to the co‑ordinator for the Independent Custody Visitor scheme for the force.

Focus groups

During the inspection we hold focus groups with frontline response officers and response sergeants. The information gathered informs our assessment of how well the force diverts vulnerable people and children from custody at the first point of contact.

Feedback to force

The inspection team provides an initial outline assessment to the force at the end of the inspection, to give it the opportunity to understand and address any concerns at the earliest opportunity. Then we publish our report within four months giving our detailed findings and recommendations for improvement. The force is expected to develop an action plan in response to our findings, and we make a further visit about one year after our inspection to assess progress against our recommendations.

Appendix II – Inspection team

• Ian Smith: HMICFRS inspection lead
• Patricia Nixon: HMICFRS inspection officer
• Anthony Davies: HMICFRS inspection officer
• Emmanuelle Versmessen: HMICFRS inspection officer
• Nicola Duffy: HMICFRS inspection officer
• Justine Wilson: HMICFRS inspection officer
• Marc Callaghan: HMICFRS inspection officer
• Vijay Singh: HMICFRS inspection officer
• Mark Calland: HMICFRS inspection officer
• Stephen Matthews: HMICFRS inspection officer
• Julie Mead: HMICFRS inspection officer
• Dayni Turney: CQC inspector
• Helen Lloyd: CQC inspector
• Bev Gray: CQC inspector

Fact page

Note: Data supplied by the force.

Force

West Midlands Police

Chief constable

Chief Constable Craig Guildford

Police and crime commissioner

Mr Simon Foster

Geographical area

West Midlands

Date of last police custody inspection

2017

Custody suites

Wolverhampton Central Custody

19 cells

Oldbury Custody Suite

60 cells

Perry Barr Custody Suite

60 cells

Coventry Custody

25 cells

Stechford Custody

16 cells

Bloxwich Custody

20 cells

Total cell capacity

200 cells

Annual custody throughput

In the calendar year 2022, 39,973 detainees entered custody.

Custody staffing

• Custody officers: 110
• Detention escort officers: 150

Health service provider

Mountain Healthcare Limited

Back to publication

Report on an inspection visit to police custody suites in West Midlands Police