Dear Madam RE: Prevention of Future Death Report following the Inquest into the death of Salton write in response to the Prevention of Future Death report dated 6 January 2014. have considered your letter and my response will address each ofthe matters of concern which you raise: Staff access to Medacs Policies and Procedures Information from the custody staff and previous medical entries
3. Correct completion of the Medacs assessment form When an individual is not assessed by a Medacs clinician
1. The access of Medacs Policies and Procedures to Medacs staff was also concerned to hear that was not aware of the Medacs Epilepsy Policy. He said in evidence that he had no specific recollection of epilepsy policy, but he was aware that the Medacs policies were available in a 'loose leaf binder in most custody suites' As a very experienced FME gave evidence that he been asked to review most of the policies, but he could not specifically recall this one. Iagree that it is important that all staff know where to look to seek guidance and where the policies are to refer to. would like to reassure you that before start work alone, all new healthcare staff complete day shadowing period with an experienced clinician During this 3 period are made aware of the content of the Medacs policies and procedures and how these can be located whilst on and are now required to sign to say they have had this information. All policies and procedures are located in every custody suite in both hard copies in a file and on the desktops of the medical room computers Every time a policy is reviewed or revised a communication is disseminated from the Head of Clinical Services via all lead clinicians by e-mail and the relevant policy is updated in the folder and the desktop. The Medacs medical room audit that is undertaken by the Lead nurses 3 months includes a standard for the policies and procedures are in both hard and soft copies in all custody suites BLTRADA Rccruitmtmt& P00/no4 4 employmemt Medacs Healthcare Confedcraliun Plaza, Salford Salford, Greater Manchester MSO 3BA Medacs Healthcare plc, an Impellam Company Tel: 0161 772 8485 Fax: 0161 772 8497 Registered Office: 802 The Boulevard_ Capability Green, Luton; LUI 3B4 Registered in England No. 2518546 Billy the had they day they duty they every ensuring Quay Quays, Group

medacs HEALTHCARE
2. Information from the custody staff and previous medical entries You advise that Medacs clinicians should receive as much information as possible from the custody staff about the detainee's medical condition and that even if they are there to solely administer medication, they should read any previous medical notes from the same stay in custody. am also keen to ensure that medical staff have all the relevant information that require in order to administer medication, and that read other relevant information which is available. Medacs staff are required to receive a verbal handover from the custody sergeant before seeing any detainee. This has been explained more fully in policy, and is included specifically in the Medacs Foundation course_ Since this Inquest a new procedure has been ratified: 'Pre and post clinical assessment guidelines for HCPs reviewing detainees in police custody' which includes that 'The HCP should discuss with the custody sergeant what medical history have gathered from the DP whilst completing their risk assessment; including any medication the DP has in their property in custody or at home and whether the DP has taken any medication prior to coming into custody_It is important that following this gathering a decision is made to whether the DP requires this medication for the time they may be held in custody and collection of this medication is requested at this time to the custody sergeant: Record this on the medical assessmentform on the care plan and on the history front sheet The HCP should read any previous entries on the custody medical assessment form to gather any further history that was given on previous arrests/ calls and enable them to start to build a and management of the DP whilst in custody The HCP may also note any changes in circumstances and health of the DP and where necessary initiate referrals to the multi service providers to encourage continuity of care at the time of release To ensure all staff are aware of this, an email was sent to all clinicians from the Head of Clinical Services in January 2014 and reminding them of the importance of pre and post assessment actions for all detainees before and after conduct their clinical assessment.
3. Correct completion of the Medacs assessment form note vour advice to remind staff of the importance of recording information on the Medacs assessment form, including a care plan and any negative answers to questions asked. agree with you that it is important for staff to record significant negatives answers, as the tendency can sometimes be to record the positive answers receive only. Unfortunately, it is not possible for staff to make a record of question asked, and every answer given, or refused to be given, but the significant information must be recorded. Clinicians are trained and audited on the use of "Medacs FME" system (the electronic record system in all custody suites) and 'The use of Medacs FME Clinical Form' is covered in the foundation training and Induction Training which includes reminding staff of the importance of completing all boxes even if there is nothing to report or a negative answer received. Care plans are recorded by the clinician on the computer and printed off for the police 4TRADA MA Recaiinie & Betnereni emmroymc Cunledcraliun Medacs Healthcare Quay Plaza Salford Quays, Salford, Greater Manchester MSO 3BA Medacs Healthcare plc; Impellam Group Company Tel: 0161 772 8485 Fax: 0161 772 8497 Registered Office: J00 The Boulevard, Capabillty Green, Luton, LUI J84 Registered in England No. 2518546 they they they history history they they every

medacs HEALTHCARE In May 2013 Medacs commenced a weekly audit of the of computer system' The Client Service Managers address any issues identified with the clinicians This is a continuing task Lead Doctors and Lead Nurses have been tasked with completing annual audits of the quality of the medical notes of all clinicians in their teams, and have been asked to address any concerns on an individual basis with staff. A re-audit is due in June 2014. Medacs are in the process of reviewing the electronic MedacsFME system to include screening tools and dropdown boxes that will make it impossible to move onto the next section without completing the information:
4. When an assessment cannot be completed fully note your recommendation that if a clinician is unable to complete an assessment that this should be explained and 'any potential misleading information should not be recorded' . Given the nature of the work in police custody, our healthcare staff frequently attend to assess detainees who refuse to co-operate. In most cases it is for the detainee to decide whether consent to an assessment, or choose to refuse, or answer questions about their health: Our Investigation report identified that in this case a nurse circled "completed" on the handwritten form re: "examination/observations completed/refused" Mr Salton had answered some questions, but refused to answer others. The handwritten forms are no longer used, and the electronic record system does not ask the staff member to select either 'complete' or 'refused'_ The electronic record system means that the clinicians Care Plan is printed out and given to the custody sergeant: this reduces the risk of different information written in the clinician' $ own records, to that written on the paperwork for the police. was of course aware Of the Inquest as it proceeded, but thank You for bringing these matters to my attention;

INq . 619/20 13 GREATER MANCHESTER POLICE RR Police Sir Peter Fahy Q.P.M,, M.A Chief Constable Y Ms Joanne Kearsley Area Coroner The Coroner Court 1u Mount Tabor Street Stockport SK1 3AG 04 March 2014 Leo ma Keas l RE: Mr: Billy SALTON (Deceased) Thank you for your report dated 6"h January 2014. In accordance with the contents of your Regulation 28 report in respect of Billy SALTON; reply to the matters you have asked me to consider as follows; During the course of the evidence, heard that Billy Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him This is as result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit (PPU) is not staffed overnight which leads to people being in custody longer than should be and bringing GMP 'up against the requirements of the Police and Criminal Evidence Act" . GMP cannot indicate how many people may have been detained in custody longer than should have been under their new policy_ Divisional Commanders hold responsibility for staffing their PPUs overnight but the reality is there are very few detainees who can appropriately be interviewed in the night Indeed many other agencies are not configured to deal with interviews during the night The Appropriate Adult Scheme, as just one example, will not turn out in night time hours as believe it is always inappropriate to interview & person who may be tired. In the case where there are no PPU officers on duty to interview, it is the Custody Sergeant's responsibility to liaise with the Operational Inspector; who acts a8 Bronze Command for that Division, to agree on resource provision to ensure the effective progress of the investigation: As you observed this often leads to a decision made to await interview in the morning because the police officers are patrolling and dealing with incidents. acknowledge that such delays in custody, whilst waiting for an interviewing fficer to be identified, have become increasingly common. Ihave an ongoing review of divisional policing entitled 'Transforming Divisional Policing' which looks at all aspects of improving the operational service we provide. have specifically asked it to look at finding ways of processing detainees with greater efficiency in order to reduce their periods of detention. GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP Tel: 101 Ianch TTcer MAR 2014 Aos they they they being

Cont.d page 2.
2. There was lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when are to be carried out, whether rousing is required and why the observations are set as are
i.e. what the medical condition/concern is_ GMP has reviewed its arrangements for communication between custody and clinical staff to negate the practice of MEDACs staff working on two separate records of notes and to improve the continuity of care provided to detainees with health needs; This has involved the installation of a computerised system for use by MEDACS clinicians; which operates within prescriptive rules requiring MEDACS to type the 708e to overcome issues of illegibility, improve continuity and to seek to ensure the details of the record are directly transcribed into the ICIS custody system: To improve clarity on levels of observations we have amended the 'drop down menus accessible to the MEDACs clinicians attending custody suites Plans are in place to enable MEDACs to directly input their care plans onto our custody system which will further improve communication between custody and clinical practitioners: training programme for all clinicians has been agreed which ensure they are trained and authorised to input onto ICIS by summer 2014. We accept there continues to be room for improvement in communication in the custody office and have engaged work programme enabling Custody Sergeants to do more managing in the custody environment and to take & greater overview of the overall working of the office and CDO's. In practice, for example, this would entail the Civilian Detention Officers undertaking specific sections of the 'booking-in' process which facilitates greater overview of the entire custody environment both front office anduback office. This programme is bedding in under the leadership of Chief Superintendent] and Superintendent
3. When the detainee is visited and checked all such visits should be accurately recorded on the custody record. We already have a process that checks custody records to ensure visits are timely and carried out in accordance with the sergeant's risk assessment It is though more difficult to check on visits that have been made but not recorded although this sometimes arises when cases are reviewed. It is commonplace for staff to say that there are sO many interactions in custody, at some point; they have to take a view on what is worthy of recording: do agree with this but can see how this can degrade into quite significant events not accurately recorded. We will, therefore, shortly be giving a series of inputs to staff which will GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 SBP Tel: 101 they they will being

Cont.d page 3 focus on recording the rationale behind risk assessments and also demonstrate to staff the importance of recording their actions as accurately as possible. The Professional Standards Branch will be involved in this programme; which will involve the use of case studies to enhance best practice Risk assessments carried out whilst in police custody should be recorded when are done If there are no changes to a risk assessment then this should be recorded and any rationale noted Since the death of Mr Salton, Custody Branch has significantly upgraded its ICIS computer system. This system prompts Custody Sergeants to undertake further reviews linked to specific/significant events affecting the detainees period of detention, including an exit risk assessment: You are right to point out that all risk assessments, including those where there is no change in the detainee's circumstances; should also be recorded. This requirement has been communicated to custody staff and is currently monitored by Custody Inspectors undertaking dip sampling of custody records.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation Proper handovers should take place as to the detained person's condition, risk assessment; any medical condition, levels of visits and other important matters We have conducted a review of handovers between sergeants. As a result we have made it clear to sergeants that the handover need not be comprehensive review of each detainee. Rather; they should have completed the Custody Summary Screen so that all the relevant detail is available on the ICIS system and the handover should contain risk issues, for example medical conditions, medication required and SO forth: It is now our operating policy that this summary screen should be accurate so that staff use the computer to ascertain information and work from this: The work programme, mentioned above, also seeks to improve communication channels in custody amongst Custody Sergeants and Custody Detention staff both handover and during the working
6. The Prisoner Escort form (PER) was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate Since your observations we have put out improved guidance on completion of the PER form to sergeants which include what to record, when it is to be done and how it is to be signed off This has been extensively checked and has led to improvements in standards. GMP Force Headquarters Central Park, Northampton Road, Manchester M40 5BP Tel: 101 will they being key key during day:

Cont.d page 4 7 There_were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them 'glancing' at the CCTV screen. At present we remain satisfied with our current arrangements for CCTV usage We do use CCTV for constant observations in some cases. However; in the case with Mr Salton, the level of observations was at Level 2 We see CCTV as something that adds value to the care plan in such situations but would not want to commit to specifically instructing staff to observe the screen at this level of observations: In the way we currently operate, we believe, this may lead to a deterioration in the level of coverage of detainees by CCTV. also am keen that CCTV use never becomes an alternative to the necessary personal contact between my staff and detainees: We are currently happy that the CCTV is optimally placed to be viewed by all staff who work in Custody: The programme Of work described earlier in improving communication and management of the office is looking at every aspect of the roles staff undertake in Custody: The monitoring of CCTV is one of those roles and will be looking for & system that matches or improves the coverage of CCTV we have and also provide greater accountability: On a final general point am concerned that Custody, which is primarily a function to achieve criminal justice outcomes; is increasingly being used to deal with issues and matters that do not lie within the scope of policing: acknowledge that we should always strive to achieve the best possible care for all detainees. However; we are undoubtedly picking up the gaps in services which should provided by other agencies: This takes our attention and resources from policing but also places officers, who are not medically trained; in increasingly difficult situations: As a force we are working with other agencies, particularly the NHS; to reduce the number of those with mental illness or other medical conditions coming into custody: Long term this would ideally include facility to deal with drunken individuals: In this day and age the concrete rooms of a custody block are not suitable places for sick people Jex< S1nceA Sir Peter Fahy Chief Constable GMP Force Headquarters, Central Park,; Northampton Road, Manchester M4O 5BP Tel: 101 they be