Frontline: Forensic medical examiner A doctor working with the police worries about the effect of outsourcing on the care of vulnerable people
“I am a forensic medical examiner, providing medical care to people in police custody – whether in hospitals or custody centres. In hospitals, I collect evidence, such as samples from patients suspected of drink driving. In the custody centre, I examine people who have been arrested to ensure that they are fit to be held in custody, fit to interview, fit to charge, and fit to transfer to court or other facilities.
Patients may have a background condition, such as diabetes, which if not managed correctly may prevent them from being detained or charged. Alternatively, they may have sustained injuries which necessitate transfer to hospital, or they may need psychiatric treatment.
In the case of mental health problems, we have to assess whether people are fit to be questioned in the presence of an appropriate adult, or we may have to liaise with mental health teams to advise them on further actions (for example, sectioning patients). We often encounter mental health issues, often combined with complex social problems such as drug addiction and homelessness.
Custody centres are officially designated a place of safety where mentally ill people can be taken. However, they are by their nature challenging environments that can potentially exacerbate mental illness: locking anyone in an eight-by-ten-foot cell is likely to psychologically affect them.
Clearly, those with mental illnesses do not belong in a custody suite for a long time, yet transfer to an appropriate facility can be notoriously slow due to the very limited availability of appropriate psychiatric assessment services. Patients can be held in custody suites for eight to ten hours.
We also provide medical support and conduct the collection of forensic evidence in the case of sexual assault and rape, from both victims and suspects. We liaise with rape support services, child support services and sexual health clinics as required. Often, long delays occur before the necessary staff can be assembled, risking additional trauma and the loss of crucial but time-sensitive forensic evidence.
The expertise to support people in custody is in increasingly short supply. This jeopardises the ability of the police to process cases in order to uphold their duty to protect public safety, and the ability of health care professionals to effectively manage risk.
I have only the highest praise for the police and jailers; I don’t know how they do it. You get the odd one who is cynical and bitter, but on the whole they are incredibly human and very good with people with mental health problems.
Some constabularies, such as my own, still employ their own forensic medical examiners. We work 12-hour shifts to ensure there is someone on duty every day, every week with a one-hour response time – you can’t even find that in the NHS! Some argue that this level of service provision is over the top, but it is difficult to see how services can be diluted any further given the challenges we face and the need to avoid deaths in custody.
However, the profession is changing hugely. All areas are now considering outsourcing their services to large contractors. The motivation is to save costs, so the contracts go out to the lowest bidder – but there is a great deal more than cash at stake. I would question whether contracting in this way can allow for effective management of
the risks that exist in a custody setting.
Contractors produce their savings by making much greater use of nurse practitioners, rather than doctors. We physicians don’t believe this is appropriate – not because nurse practitioners don’t perform a valuable role, but because they are not empowered to deal with some of the issues we face. For example, as soon as a patient says they feel suicidal – which they often do when in custody – a nurse practitioner must call a doctor. The constabularies then get charged for calling out a doctor, as well as paying for the nurse.
If I had a chance to speak to a senior civil servant or minister, I’d ask them to think of the human side of the justice system. It’s easy and emotive to talk about criminals, but most people who are held in custody suites are desperate, ill, victims, or perhaps young people who have had too much to drink. If they were your son or daughter, you’d want them to be treated with dignity and receive the appropriate treatment, particularly if they are mentally vulnerable or have been victims of a crime.
I would also ask the government to think twice before they outsource any service. You can only cut a service once – and when those skills and capabilities have gone, they’re very hard to reinstate.”