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Tighten standards or risk harm in custody, warn forensic nurses

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More people could die or suffer harm in police custody unless the NHS tightens new standards for nurses and other professionals working with this vulnerable group, claim forensic nursing experts.

A failure to ensure those working in this complex and challenging field have the right skills also risks putting put inexperienced staff under intolerable strain and driving them away from the profession, say nurses who have called for urgent revisions to service specifications.

“You are working with highly complex individuals with chaotic lives and drug and alcohol dependence”

Jennie Smith

The warnings come amid changes to the way services are run with responsibility for funding and commissioning custodial healthcare due to transfer from individual police forces to the NHS from April next year.

NHS England is in the process of finalising national service specifications for contracts. However, forensic nursing leaders fear that in their current form the plans fail to ensure nurses working in such services possess appropriate qualifications.

A version of the NHS England document seen by the professional bodies has been described as “weak” and “woolly”, with the risk that services could employ under-qualified staff, ill-equipped to deal with highly vulnerable patients.

“We see this job as an advanced practice role,” stressed Jennie Smith, president of the UK Association of Forensic Nurses (UKAFN).

“You are working with highly complex individuals with chaotic lives and drug and alcohol dependence, where often their only point of contact with healthcare is you,” she said.


Jennie Smith

“You are doing comprehensive assessments, potentially diagnosis things and then managing those conditions along with the huge criminal justice responsibilities involved. If you don’t have the experience things can be missed,” she added.

She said there was a risk detainees could suffer or die if nurses did not have the right qualifications and training.

“That is potentially the worst case scenario and it is also unfair on nurses to be put in a job they are not capable of doing,” she said.

It was particularly important to set clear workforce standards in a field dominated by private providers, she added.

“Private providers have their bottom line to think about and don’t necessarily want to pay competitive rates so by default you get staff with less experience applying for these jobs,” she said.

“This is a top band 6 or band 7 job but you end up with band 5 and new band 6s applying with limited experience,” she told Nursing Times.

“The healthcare professional characteristics need to be tight so providers – whoever they are – can’t get away with putting ill-equipped and ill-qualified nurses in these roles,” said Ms Smith.

“They are working at this advanced level in a very challenging environment where they might be making decisions while under pressure from police officers”

Margaret Bannerman

The UKAFN, the Faculty of Forensic and Legal Medicine (FFLM) – which sets standards for all healthcare professionals directly involved in the clinical care and forensic medical assessment of detainees – and College of Paramedics have joined forces to call for explicit standards to be included in the service specification document.

As a minimum, they say all nurses, paramedics and doctors working in forensic or sexual offence medicine should either be officially licensed by the FFLM or be qualified to UKAFN’s Advanced Standards in Education and Training (ASET).

Meanwhile, they have urged Dame Elish Angiolini, who was recently appointed by the government to lead a review into deaths in police custody, to look at standards of healthcare provision and examine the relationship between quality and the qualifications of professionals involved.

UKFAN education officer Margaret Bannerman, a registered nurse, was instrumental in developing ASET, created specifically for nurses and paramedics to recognise the unique combination of skills required for working in police custody.

“Nurses in these roles are completely autonomously responsible for the health and wellbeing of an undiagnosed individual and by definition are advanced practitioners,” she said.


Margaret Bannerman

“They are working at this advanced level in a very challenging environment where they might be making judgements and decisions while under pressure from other professionals such as police officers,” she said. ”This is not a role for a newly-qualified practitioner.”

She said employing under-qualified nurses in such roles was a false economy and risked deterring people from working in police custody, where there were already recruitment and retention issues.

“If you put someone inexperienced in that role they may be pressured into making wrong decisions, mistakes will be made or they will feel very vulnerable and unsupported so they are not going to stay,” she said.

Ms Bannerman is an associate professor of enterprise and education development in the faculty of health sciences at Staffordshire University, the first higher education provider to offer a post-graduate qualification based on ASET.

She said UKFAN was keen for more universities to develop similar awards so more nurses could access training.

“We are working closely with these organisations and others to develop national standards for when responsibility for commissioning these services transfers to NHS England”

NHS England

She acknowledged concerns that specifiying qualification levels could prompt a “crisis” in the field with providers struggling to recruit new people at that level or train up existing staff.

“The reason we are standing up to this is about clinical standards and making sure people get the best care,” she said. “It would need to be resourced and people may say they can’t afford it by my response is they can’t afford not to.”

Custodial healthcare providers and commissioners across England have successfully worked together to develop accredited standards for induction training.

Ms Bannerman, who has led the project, said this was an example of what could be achieved if people were willing to embrace change.

NHS England said it was reviewing the service specifications and was aware of the concerns expressed by UKAFN and other bodies and took their views seriously.

“We are working closely with these organisations and others to develop national standards for when responsibility for commissioning these services transfers to NHS England next year and will continue to do so,” said a spokesman.

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