Fitness for detention in police custody: A practical proposal for improving the format of medical opinion

Abstract

Health issues among arrestees are a worldwide concern for which only local policies have been established. Physicians attending detainees in police custody are expected to decide whether the detainee's health status is compatible with detention in a police station and make any useful observations. A high degree of heterogeneity in the information collected by the physician and transmitted to the police has been observed. We analyzed the content and limitations of available documents and developed a model that could serve as a guide for any attending physician. The document presented here has been used in France on over 50,000 occasions since June 2010. We developed a two-page template consisting of (1) a standard medical certificate to be sent to the authority who requested the doctor's attendance and (2) a confidential medical record, not sent to the requesting authority. We evaluated perceived health by the three global health indicators of the Minimum European Health Module and used DSM IV criteria for the evaluation of addictive disorders. In the case of recent traumatic injuries, the certificate has also included the collection of data on traumatic injuries and the contexts of their occurrence. The proposed certificate achieved several goals, by protecting the interests of the person examined, in case of poor conditions of arrest or detention, protecting doctors in cases of legal proceedings, and allowing epidemiological data to be collected. The certificate may also contribute to an international awareness of medical care for detainees in police custody.

Introduction

Health issues in arrestees are a worldwide concern for which only local policies have been established to date.1, 2, 3 International standards recommend that a detainees' right to medical care be equivalent to that available to the general community.4, 5 In the UK, the British Medical Association has stated that detainees in police stations are entitled to standards of health care equal to those in the National Health Service.⁶ However, as conditions in police stations for detainees under custody are often demeaning,7, 8, 9, 10 any underestimated health damage can have critical consequences, including death.¹¹ Available data on deaths in police custody cited the following as the most frequent causes of deaths: acute alcoholic intoxication, deaths by hanging, cerebrocranial traumata, fatal intoxication with medical or illegal drugs, and death related to restraint for excited delirium.11, 12, 13 Ill-treatment, which could affect as many as 15% of detainees,¹⁴ is a matter of concern in a number of countries.15, 16, 17, 18 In two studies from Spain, the vast majority of medical documents was found insufficient in their appraisal of exposure to ill-treatment of arrestees.15, 19 Three facets of medical intervention in police custody that may stand in conflict with one another have been identified: first, a role of a medico-legal expert for a law enforcement agency; second, the role of treating doctor; third, the examination and treatment of detainees who allege that they have been mistreated by the police.¹ In France, any arrestee is entitled to a medical examination in police custody. The entitlement to a medical examination also exists in Spain, but not in Belgium, Denmark, Germany and Italy.²⁰ According to French Law, any forensic physician, general practitioner, or emergency doctor may be asked to examine detainees. The attending physician must assess whether or not they are fit for detention. The doctor's opinion is expressed in a medical certificate to be sent to the authority who requested the doctor's attendance. The issues of confidentiality of detainees' medical records and of their statements to the attending physician have long been highlighted in a number of countries.21, 22, 23 In the UK, this included a 1993 Lancet editorial¹ and recommendations from the BMA Medical Ethics Department and the Faculty of Forensic and Legal Medicine.⁶ The French Code of Criminal Procedure specifies that the medical certificate must be attached to custody records, but does not specify its content.²⁴ A high degree of heterogeneity in the editorial information collected by the physician and transmitted to the police has been observed in several countries.3, 21, 25 Some questionnaires have been published in the UK, that ranged from a crowded one-page to a four-pages pro forma document published on behalf of the Faculty of Forensic and Legal Medicine.25, 26 In 2004, a national consensus conference in France gained support from the French Medical Association, the French Society of Legal Medicine, the French College of Forensic Physicians, and the Ministries of Health, of Justice, of Interior, and of Defence. It stated that medical practice in this field should be harmonized and that the doctor's opinion should take the form of a two-page uniform document consisting of two parts.⁸ In the UK, the Faculty of Forensic and Legal Medicine also made some recommendations.⁶ The first page consisted in the medical certificate transmitted to the police and did not include clinical data, and the second page constituted the confidential medical record.8, 27 Five years later, this form was still rarely used throughout the country, possibly because of defects in its content. Our objective was to develop a document that could guide any attending physician to carry out all facets of their duties. The document presented here has been used in France, albeit with no legal obligation, on over 50,000 occasions in medical examinations of detainees performed in custody suites or in hospitals since June 2010.