Modification of the examination of fitness for custody as a result of external factors in the period 2013–2018

Previous studies have shown that the assessment of fitness for custody is influenced by external factors. In this study, we analyzed whether the changes that occurred in the period 2015–2016 (predominant involvement of forensic medicine, significant increase in the proportion of the population with a migration background) had an impact on the examination of fitness for custody in the Halle/Saale area (Germany). A retrospective analysis of 1271 examinations of fitness for custody from the period 2013–2018 was carried out. Therefore, two periods (2013–2015 and 2016–2018) were considered and the various parameters were evaluated using several statistical programs. In terms of the reasons for examination, there was a significant decrease in alcohol intoxication and a significant increase in psychiatric illnesses (p = 0.016) in the period 2016–2018. Regardless of the time period there was an increase in examination time of approximately 3.5 min for examinations of people with a migration background. In comparison of the two time periods, fewer persons examined were fit for custody without restrictions and significantly more were fit for custody with restrictions only (p = <0.001). The present study confirmed the influence of external factors on examination of fitness for custody. With the predominant involvement of forensic medicine, there was a significant increase in persons with limited fitness for custody. The increased proportion of persons with a migration background resulted in a broader variety of indications as well as an increase in examination time and the involvement of interpreters. For the future guarantee of the examinations, these changed circumstances must be taken into account, also including appropriate payment.


Background and question
For several decades, the assessment of medical fitness for police custody in the region of Halle/Saale has been carried out with varying intensity involving forensic medicine and an accompanying systematic evaluation. Between the periods 1997-2003 and 2006-2010, significant dif-ferences in the indications for medical consultation and in the decisions on fitness for custody were evident [9], primarily due to the new police custody regulations introduced in 2006.
In the period 2013-2018, especially two other factors were observed that might also have triggered changes. In 2014, an agreement was reached between the po-lice directorate and the University Hospital to determine that the examination would be one of the duties of the on-call forensic medical service. Initially, however, this examination was often carried out by a separate team of other physicians from different disciplines. Only from 2016 onwards, was there an increased use of the forensic physicians, resulting in the fact that since 2018 the examination has only been carried out by other physicians in rare cases. Furthermore, an increase in the proportion of the population with a migration background (primarilyrefugees and foreigners), which began in 2015, was suspected to have led to higher demands in terms of time and personnel, while other conditions remained the same. The aim of this study was to examine the extent to which these changes have led to a modification of examination of fitness for custody.

Material and methods
A retrospective analysis of the examinations from the central police custody in Halle (Saale) for the period 2013-2018 was conducted. For this survey, a review of all original protocols was done, whereas the following parameters were recorded pseudonymously: -Frequency of physician involvement -Gender -Age group -Indications for consultation -Duration of the examination -Examination within or outside normal working hours -Decision on fitness for custody -Requirements in case of limited fitness for custody -Recommendations in the event of lack of fitness for custody -Migration background -Presence of a language barrier -Necessity to consult an interpreter In order to detect the changes, the data was divided into two 3-year periods: 2013-2015 and 2016-2018; however, the proportion of influencing factors could not be separated exactly, as an increasing proportion of persons with a migration background was already recorded in the second half of 2015, and in 2016 the proportion of forensic medical expertise only gradually increased again.
Part of the acquired data had already been used in another retrospective study [12], which focused on the recording of specific medical risk profiles and their evaluation regarding emergency medical aspects, but in contrast to the present study, only the total collective was considered there.

Results
In the entire study period 1271 of the 3335 persons taken into custody underwent medical consultations, resulting in a frequency of medical consultations of 38.1%. These cases were almost equally distributed, with 635 in the first period (2013)(2014)(2015) and 636 in the second period (2016-2018). Since a total of 1574 persons were taken into custody in the first period and 1761 persons in the second period, the proportion of cases with necessity of medical consultation decreased from 40.3% to 36.1%.
In order to classify the indications for medical examination, the criterion was selected which was in the foreground during the assessment (. Fig. 1). In about one third of all cases (32.7%, n = 416), it was acute alcohol intoxication, followed by alcohol/drug/medication with-drawal syndromes (14.4%, n = 183). Drug/ medication influence (11.8%, n = 150) and trauma (12.0%, n = 152) were almost equal in third place, followed by internal (10.2%, n = 130), non-specific (8.0%, n = 102) and psychiatric (6.5%, n = 82) indications. The proportion of other specific indications (such as epilepsy) was low (4.1%, n = 52) and rare diseases (e.g., narcolepsy, cataplexy, congenital genetic defects) represented just a rarity at 0.3% (n = 4). When comparing the two study periods, alcohol intoxications were significantly more frequent in the first period than in the second (p < 0.001); however, the trend towards a decrease in alcohol withdrawal syndromes from the first to the second period, as shown in . Fig. 1, was not quite significant (p = 0.053). In contrast, psychiatric diseases were significantly more frequent in the second period (p = 0.016). The occurrence of the remaining reasons for the medical examinations did not change significantly from the first to the second period.
Averaged over the entire study period, a medical assessment took about 27.2 min, ranging from 5 to 180 min. The average examination time in the first period was 25.0 min, whichwas shorter thaninthe second period (29.5 min). Most examinations (88.7%; n = 1128; 575 vs. 553) took place outside regular working hours (weekdays 07:30-16:00), with no noticeable difference between the two periods.
For further statistical evaluation of the duration of the examinations, a multiple regression of the entire dataset was performed. In particular, the aim was to clarify whether there was a correlation between the duration and the time of the examination (first or second period) and whether, independently of this, a migration background of the person examined also had an influence on the duration of the examination. There was no indication of a statistically significant interaction between the time of the examination (first vs. second period) and the presence or absence of a migration background (b = -1.51; SE = 2.112; t = -0.71; p = 0.48). As the presence of a language barrier and a migration background were strongly correlated (Pearson's productmoment correlation: r = 0.80; p < 0.001; t = 48.15; df = 1269), we decided not to Regarding the medical decision after the examination, in 75.4% (n = 958) of all cases in the entire study period (2013-2018) a limited fitness for custody was conducted. In a total of 17.4% of cases (n = 221), unrestricted fitness for custody was determined, while over both periods, approximately equally distributed, lack of fitness for custody was assessed in a total of approximately 7.2% of cases (n = 92). In the first period, unrestricted fitness for custody was confirmed significantly more often (χ 2 -test, p < 0.001) (. Fig. 2). In contrast, limited fitness for custody was certified significantly more often in the second period (χ 2 -test, p < 0.001).
In the cases with limited fitness for custody, several medical recommendations were often made. The most frequent recommendation (59.9%, n = 761) was to re-quire a new medical examination in the case of a considerable deterioration in condition. In descending order of frequency, 43.8% (n = 557) of cases involved a recommendation of more frequent checks (than specified in the detention order) and in 33.7% (n = 428) the use of a video surveillance in the detention cell (video cell) was suggested. Recommendations on food and fluid intake, at 15.3% (n = 195), and on taking medication, at 11.0% (n = 140), were also relatively frequent. Less frequent were recommendations to see a specialized physician (5.9%, n = 75), to limit the period of detention (3.4%, n = 43) or to be placed in a large cell (1.0%, n = 13). In 10.2% (n = 130) of cases, other measures (e.g., checking awakenability, sitting guard, changing bandages) were used. With the exception of the latter option, all recommendations were used more frequently in the second period (. Fig. 3).
Amongthe92 cases withalack of fitness for custody, hospitalization was recommended most frequently for the group of other specific indications (e.g., diabetes, post-myocardial infarction, epilepsy or injuries requiring surgical treatment), at 41.3% (n = 38). In descending order of frequency, hospital admissions were recommended for mental illness or disorder (21.7%, n = 20), severe traumatic brain injury (12%, n = 11), alcohol intoxication (6.5%, n = 6), alcohol withdrawal syndrome (5.4%, n = 5) and advanced drug withdrawal syndrome (2.2%, n = 2). In addition, there were seven cases (7.6%) in which the persons were transferred to home care and three cases in which a positive assessment could not be issued due to refusal of the medical examination. When comparing the two periods, alcohol-related hospital admissions were more frequent in the first period, while mental diseases/disorders, traumatic brain injuries and other specific indications that led to hospital admissions were more frequent in the second period (. Fig. 4).
According to the information on nationality or country of origin in the detainees' custody documents, at least 25.0% (n = 318) of cases involved a migration background. Furthermore, alanguagebarrier was present in at least 18.2% (n = 232) and an interpreter was called in for 14.2% (n = 181). The frequency of these three

Discussion
A previous investigation of the fitness for police custody in the region of Halle (Saale) has already shown highly significant differences in the indications for consulting a physician and in the medical decisions [9]. These changes were mainly due to a newly introduced police custody order in which medical aspects were strictly reg-ulated. The influence of external factors on the outcome and circumstances of the examination of fitness for custody could also be demonstrated in other studies. For example, the involvement of nurses in the North of England led to faster response times and better cooperation with police officers [4]. In Hamburg (Germany), lowthreshold hospital admissions could be avoided during the G20 summit through cooperation between forensic physicians and trauma surgeons [13]. It is also known from studies concerning deaths in police custody that changes in outcome can be achieved by modifying external influencing factors. In Norway, for example, a reduction in police custody as well as more frequent medical consultations and video surveillance led to a significant decline in such deaths [1,2]. In Nebraska (USA), a decrease in suicides because of prevention measures and training programs was the main cause [18,19].
The present study included 1271 cases, which were divided into two investigation periods (2013-2015 and 2016-2018),each with almost the same number of arrested persons investigated, due to the external The frequency of medical consultations for the entire period was similar to the period 2006-2010 (39.4%) with an average of 38.1% [9]. This ratio is in the upper range compared to all German states [24], which lies between 5.5% and 48.3%. The reason for this could have been an increase in awareness due to several deaths in the last two decades that attracted a lot of publicity [9,10]. A possible reason for the somewhat lower frequency of investigations in the second period could be the increased involvement of forensic physicians since 2016. Due to conflicts with other obligations in the forensic on-call service, the agreement on a case-related critical review of the indication for medical consultations was made with the responsible police directorate. Thus, for example, examinations of alcoholized persons without relevant deficits or significant concomitant illnesses, that were otherwise routinely requested, were avoided. Age and gender distributions, with a dominance of males and younger age groups, shows considerable consensus with other European studies [3,11].
The indications for medical consultations were in accordance with other European studies in which intoxications and corresponding withdrawal syndromes were predominant [3,14,16,23]. In the entire period, the spectrum of reasons for medical examinations was even more diverse than in the previously studied period from 2006-2010 [9]. The decrease in acute alcoholization with a simultaneous increase in drug/medication influences is most likely due to corresponding changes in consumption habits in Germany [5]. The increasing share of internal, nonspecific and psychiatric indications could be explained by the rise in the proportion of persons with a migration background to 25%. Although, according to the World Health Organization, migrants and refugees usually have a good general state of health, there is often an increased risk of a number of acute and chronic diseases, especially mental disorders and diseases, during migration or during their stay in host countries due to unfavorable living conditions or changes in lifestyle habits [25].
Almost 90% of the medical examinations had to be performed outside regular working hours, which is in agreement with other studies [6,9]. The average duration of the examinations was approx. 24.5 min in the first period and then increased significantly by more than 4 min. There seems to be a clear discrepancy in the quality of individual examinations, as their duration ranged from 5 to 180 min. The main reason for this could probably be the lack of national and international examination stan-dards. If an examined person has a migration background, a language barrier or the need for an interpreter, an additional significant increase of the examination duration by approximately 3.5 min. Therefore, the examination of a person with a migration background in the second period took an average of almost 8 min longer than for other persons in the first period; however, other factors, such as the more frequent involvement of forensic physicians with their background knowledge of legal consequences and the more diverse spectrum of indications, can also be considered for the increase in the duration of examinations in the second examination period.
In terms of medical decisions, it appeared that cases with lack of fitness for custody were rarely found (7.2%). In other German studies, this proportion was significantly higher at 17.2% and 11.9%, respectively [11,24]. In the present study, a clear dominance of cases with limited fitness for custody was evident (75.4%). When comparing the two periods, it became apparent that this option was used significantly more frequently in 2016-2018 and that a continuous increase could be observed with respect to earlier studies from Halle (Saale). While the proportion of those who could only be detained with medical restrictions was 16.7% in 1997-2003, it had already risen to 60.4% in 2006-2010 [9]. This development may be explained by the continuous systematic evaluation and resulting tendency towards increased examination accuracy. Correspondingly, medical restrictions were also given more frequently during this period. The most frequently used requirement to initiate a new medical presentation in the event of a deterioration of condition actually should be a standardized procedure. The increased use of video surveillance, which was required in 60% of the cases in the second period, may also be due to an increasing improvement in the technical equipment of custody cells [12]. The heterogeneous group of "other" indications dominated the cases with lack of fitness for custody at 41.3%, which accounted for only about 10% in 2006-2010 [9]. This emphasizes the range of indications, which had become significantly more diverse by 2018, and should prompt a recategorization of the previously selected range of indica-tions. Hospital admissions due to mental illnesses or disorders also continued to rise in the second period. The fact that these indications already accounted for about a quarter of all hospital admissions in 2006-2010 should be sufficient reason for appropriate agreements between psychiatric hospitals and police stations [9].
During the study period, there was a significant increase in cases with a migration background (20.3% → 29.7%), which corresponds to the development of the migrant population proportion in the region of Halle (Saale) (4.5% → 9.6%) [8,17]. In addition, there was a considerable increase in examinations with a language barrier. In the entire period, the proportion of these cases accounted for 18.2%, but the involvement of an interpreter was considered necessary in only 14.2% of the cases; however, it should be part of the physician's responsibility to insist on the involvement of an interpreter when there is a lack of communication [9,22], even if this implies an increased expenditure of time, money and personnel.

Conclusion
In the present study, it was confirmed that the circumstances and the results of medical examinations of fitness for custody are influenced by external factors. Thus, in addition to a change in the frequency, there was also a broader range of indications for a medical consultation, making it difficult to prioritize a certain medical speciality for this examination. Furthermore, an increasing tendency to attest a limited fitness for custody by issuing restrictions was observed. This development, in addition to the increased effort due to more frequent language barriers, appears to be the reason for the increase in the required examination time.
However, the increased requirements for the assessment of fitness for custody due to the more diverse range of indications and increased examination time are currently not reflected in the liquidation options. Currently, the payment for an examination in police custody varies between 51.29 and 97.34, depending on the day of the week and time of day, and is thus similar to the payment of a forensic blood sample, which requires significantly less effort and medical responsibility. In this context, the withdrawal of physicians from other specialties from such examinations, usually carried out at night, which has been observed since 2016, is quite reasonable. The subsequent repeated attempts by the police department to recruit physicians for those examinations failed. If police departments do not succeed in establishing agreements of responsibility, such as with the Halle University Hospital, serious problems regarding the realization of such examinations are imminent. Besides liquidation issues, this is due to legal, professional and ethical concerns [20]. Since this problem is also known to occur in other regions of Germany [9], the increase in requirements and the extent of physician's responsibility should be brought into an appropriate relationship by means of liquidation. Likewise, clarification of responsibilities of physicians is necessary in accordance with the respective regional (health) care structures. Otherwise, there is a significant risk that the necessary and responsible task of assessing fitness for custody can no longer be guaranteed adequately or only with considerable delays. This could further increase the already considerable risks of health damage and death in police custody [15,26].