The forensic roleAssessing fitness to detainThis is one of the most commonly requested examinations performed by the forensic paramedic and may be required in connection with adults or juveniles following arrest for an alleged offence, an initial mental health assessment where custody staff have concerns over the mental welfare of a detained person (DP), those detained by immigration, and those on remand or sentenced.The forensic paramedic must consider the health, safety and wellbeing of a detainee to be of paramount importance and concerns for this may at times override forensic considerations. In simple terms, if the forensic paramedic would be concerned at leaving the person at home with no supervision or care, then the detainee may not be fit for detention.The forensic paramedic must be aware of the conditions related to detention and although medical conditions may not be life threatening, there are times when continued detention may not be desirable for the care of the detainee.Full discussion with custody staff may enable a mutually agreed acceptable management plan, e.g. bailed to attend another day for interview, or attendance at hospital etc. This may be influenced by consideration of the level of charge in terms of the serious nature of the offence. If the forensic paramedic recommends release, they should enquire whether community care is available or consider hospital referral.The purpose of the examination for fitness to be detained (FTBD) is to assess illness, injuries, problems related to substance misuse—including alcohol—and mental health disorders. Forensic paramedics give advice to custody staff to enable them to care for the detainee during detention, and to determine those detainees not FTBD and who need diversion to other healthcare services. Many detainees have complex healthcare needs and often advice regarding necessary medication and the need for review by either FME or a crisis team, as required.The forensic paramedic may be approached to assist the police with information to aid their investigation. This can create a conflict of interest and the forensic paramedic must be prepared to justify the sharing of any information at a later date if necessary.Fitness to interview and chargeThe importance of assessing a detainee's fitness for interview, lies in the well-established fact that certain vulnerable individuals may make false or misleading statements to the police that are not in their best interest. A careful and well-documented examination is necessary to recognise such individuals and ensure that appropriate safeguards are in place, and to rebut subsequent defence claims that a detainee's confession should be ruled inadmissible because they were unfit for interview at the time of the confession.Annex G of PACE Codes of Practice, Code C, contains general guidance to help police officers and healthcare professionals assess whether a detainee might be at risk in an interview. A detainee may be at risk in an interview if it is considered that conducting the interview could significantly harm the detainee's physical or mental state, or anything the detainee says in the interview about their involvement or suspected involvement in the offence about which they are being interviewed might be considered unreliable in subsequent court proceedings because of their physical or mental state.A personal viewWhen I qualified as a paramedic in 1988, I never thought I would end my NHS career involved in the field of forensic practice. After a career of 28 years with the ambulance service, which gave me opportunities ranging from being a member of an air crew to international work, I left in 2005 to pursue a career in primary care as an emergency care practitioner with a primary care trust (PCT).I quickly moved to another PCT that was providing custody cover on a trial basis in the North East on a 24-hour seven day a week operation with ECP’s employed in that area. Due to the success of this trial, from 1 May 2007 further custody suites were added, making it a countywide service covering six custody suites.The contract was further expanded and eventually went to tender for full service. I applied for and was successful in my application for the position of clinical lead for the contract management. I retired from the NHS in 2012 after the NHS won the contract to provide all medical services to the constabulary.During my time as the contract manager I was responsible for developing a training package for practitioners. This training included custody suite training, police custody evidential issues, safety awareness in custody, and forensic sampling. I also studied offender health and substance misuse. I found it very difficult to find academic training suitable for practitioners in advanced forensic practice.The United Kingdom Association of Forensic Nurses (UKAFN) is working to establish professional standards for forensic nurses in both the sexual assault examination and custody areas of forensic nursing. I joined UKAFN and became a paramedic member of the steering group with a recent appointment of treasurer. I am looking forward to starting the UKAFN approved Postgraduate Certificate in Advanced Forensic Practice, which was developed with the Faculty of Health at Stafford University. The NHS commissioning of custody healthcare will demand professional standards; UKAFN have been working with the Faculty of Forensic Legal Medicine (FFLM) to set professional standards for forensic practitioners.When healthcare professionals identify risks, they should be asked to quantify the risks. They should inform the custody officer: whether the person's condition is likely to improve, whether the condition requires or is amenable to treatment, and how long it might take any improvement to take effect.Any suspect will be unfit for interview if they have a physical or mental illness that is likely to deteriorate significantly because of the delay in obtaining treatment that the interview will engender, or as a result of the stress of the interview.As part of the holistic assessment, the forensic paramedic must be able to assess whether a detainee should be interviewed, considering how the detainee's physical or mental state might affect their ability to understand the nature and purpose of the interview. The extent to which the detainee's replies may be affected by their physical or mental condition rather than representing a rational and accurate explanation of their involvement in the offence and how the nature of the interview, which could include particularly probing questions, might affect the detainee.The forensic paramedic must consider the various vulnerability factors that render an individual more likely to provide an unreliable confession. Factors that need to be considered include the health of the individual (physical and mental, including substance misuse), the likely demand characteristics of the interview, personality traits that increase vulnerability, and the totality of the circumstance.Detainees presenting with mental health problems are common in police custody; it is not uncommon to see people in crisis. Although mental health is an important factor in determining the reliability of testimony, it should be recognised that the fact that a suspect suffers from an illness does not necessarily mean that they are unfit for interview.Detainees with learning disabilities may have difficulties in understanding their legal rights and in communicating with police officers. They are also more likely to be suggestible, acquiescent and more prone to providing false confessions; therefore, an appropriate adult will have to be considered for the interview process.Significant intoxication by alcohol or drugs will make a person temporarily unfit for interview.The decision regarding the fitness for interview of a suspect who has been drinking or misusing drugs should be based on a medical and functional assessment to give an estimated time for fitness.A person suffering from alcohol or drug withdrawal is, in some ways, especially vulnerable to giving a false confession. Such persons may believe that compliance will result in early release and that the risks entailed in providing a false confession may seem worthwhile in the presence of an overwhelming desire to re-establish access to their supply of drugs or further alcohol. Drug withdrawal states can markedly affect levels of anxiety and prevailing mood, which may increase suggestibility and compliance.Any detainee displaying signs or symptoms of alcohol or drug withdrawal is managed using Patient Group Direction (PGD) medication to manage withdrawal and to prevent the detainee being under duress. Occasionally, when a detainee dependent on alcohol starts to fit, a trip to an accident and emergency department is required.Other assessmentsOther aspects of the forensic paramedic's work can include taking intimate samples with lawful authority, and consent for suspects involved in sexual assault and violent crimes.The taking Road Traffic Act (RTA) blood samples from a driver that has failed a roadside breath test and provided a boarder line reading during the station procedure is another common call for the forensic paramedic.Many detainees, as previously stated, have very complex healthcare needs and require their own medication during attention. Verification of medication for use in custody requires a full medical and medication history, including substance use. Own medication brought into custody must be appropriately labelled, packaged, dated, and regularly used.Recording of injuries is required for either complaints or evidential reasons that have to be recorded on body maps, including a description of the type and size of the injury. Once the injury is recorded, if possible it will be dealt with in custody, if not, then the police escort the detainee to hospital.Writing statements and appearing in court as a professional witness is part of the role of the forensic paramedic. Writing the first few statements and attending court can be a daunting prospect, which thankfully has not happened that often.
