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The Medical Determination of Fitness for Detention in Police Custody
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Background: In Germany, police custody is used to prevent danger. An arrested person’s medical fitness for police custody must be assessed by a physician if it is in doubt. The frequency of such examinations among arrested persons in Germany ranges from 5.5% to 66.0%. There are currently no binding guidelines for the assessment of fitness for police custody.
Methods: Current police custody regulations across Germany were obtained from the internet and from the interior ministries of the German federal states. Epidemiological features and risk profiles were determined from relevant publications retrieved by a selective search and from the authors’ own current data. Practical recommendations were derived from this information.
Results: Regulations concerning police custody vary widely across German states. The main indications for medical assessment are intoxication (36.8–65.7%) and withdrawal syndromes (14.4–24.7%). Medical assessment usually results in a determination of unrestricted fitness for police custody (32.5–64.6%) or of restricted fitness subject to certain conditions (16.7–75.4%). Mental illness (21.7–25.0%) is a common reason for being unfit for police custody.
Conclusion: In Germany, no particular individual or body is specified by law as being responsible or qualified for assessing fitness for police custody. When such an assessment is to be made, the state regulations should be known, and a state-specific assessment form and certificate of fitness for police custody should be developed if the legal basis is inadequate. A standard operating procedure (SOP) should be created for use in hospitals as well. It should be stated in the certificate whether the person in question is fully fit for police custody, fit for police custody with restrictions, or unfit for police custody.
Cite this as: Heide S, Dettmeyer R, Michels G, Berg A, Lange J, Rothschild MA: The medical determination of fitness for detention in police custody. Dtsch Arztebl Int 2025; 122: 701–8. DOI: 10.3238/arztebl.m2025.0198
Police custody is a preventive deprivation of liberty that serves to avert a present danger or prevent the imminent commission of a crime. Its legal basis is derived from the policing laws and police custody regulations of the German federal states and the national government. According to Article 104 of the Basic Law (Grundgesetz), no one may be held in police custody beyond the end of the day after their arrest. A court order can extend the permitted duration of custody to a period of four days to one month. If there are indications that a detained person is at risk of health problems, a medical assessment of his or her fitness for police custody (synonyms: suitability or capacity for being held in custody) is required (1). Depending on the jurisdiction, 5.5% to 66% of people arrested in Germany undergo a medical examination (2, 3). As early as 2003, the German Medical Journal criticized the lack of examination standards and guidelines for assessing fitness for police custody (4). Despite documentation from all over the world of the major risks to health and life that are associated with police custody, there are still no uniform guidelines in Germany. This is due, in particular, to the lack of specification of medical responsibility, and the country’s legal federal structure (5, 6). Hospital emergency rooms and emergency centers are regularly confronted with the need for such examinations, and thus a clinically oriented, standardized procedure has already been proposed (7). In this review, we describe the current framework conditions in Germany and the medical risk profiles of persons held in police custody (8, 9, 10) and derive interdisciplinary conclusions and recommendations for action.
Learning objectives
This article should enable the reader to:
- state the legal requirements, tasks, and knowledge necessary for a medical assessment of fitness for police custody,
- understand the requirements for the framework conditions and the quality of the medical examination, and
- recognize typical problem areas of this medical activity, in order to make a medically valid assessment of fitness for police custody, with conditions attached if necessary.
Materials and methods
In Germany, the maximum duration of police custody is specified by the policing laws, while other aspects are regulated by the custody regulations of the states and the federal police. The current police custody regulations were evaluated between February and August 2025. Only some of these are available on the internet; most had to be requested from the state interior ministries. Epidemiological characteristics and risk profiles were determined from our own data and a selective literature search in PubMed, Google Scholar, and other databases. The recommendations for action were formulated on the basis of the legal regulations, the literature search, and our own practical experience.
Current German regulations on medical aspects of fitness for police custody
The medical aspects of fitness for police custody still vary widely from country to country (5, 6) and from one German state to another (11) and can only be described in broad terms.
Reasons for consulting a physician and medical responsibility
The German state of Saxony has formulated a list of twelve criteria for consulting a doctor; other states specify far fewer reasons. The most detailed guidelines can be found in the state of Saxony-Anhalt (eTable 1). Evident illness, alcohol and/or drug intoxication, and physical injury are commonly listed. Medical responsibility is rarely specified concretely. Only in Hamburg is it mandatory to consult a doctor from the Institute of Legal Medicine in cases where a police custody certificate has been clinically refused.
Monitoring of detained persons
There is marked variation in the medical monitoring of persons in police custody (eTable 2). In the quantitative control mode, unspecific terms such as “appropriate” or “regular” are rare; more commonly, specific control intervals are specified. Qualitative requirements (e.g., a test of arousability) are rare. In Hamburg, sleeping persons must be shaken awake and spoken to at least every half hour, but there should be no interruption of the normal sleep phase.
Further conditions and medical documentation
In some of the German federal states (Baden-Württemberg, Brandenburg, Rhineland-Palatinate, Schleswig-Holstein, Saxony, Saxony-Anhalt, Thuringia), the regulations on written documentation give physicians an opportunity to state further conditions for permissible police custody. In Saxony, for example, these may involve drug administration, further medical examinations, altered monitoring intervals, and a police custody time limit (eBox). In Saxony-Anhalt (12) and Baden-Württemberg, medical documentation forms of up to four pages’ length must be completed. In Bavaria, on the other hand, a medical certificate is desirable but cannot be judicially demanded. In Bremen, too, the physician may decline to submit a certificate.
Procedure in the event of unfitness for police custody
Only a few states specify the procedure in the event of unsuitability for police custody. For example, the federal police require immediate medical treatment for persons who are confused, unconscious, unresponsive, or show signs of poisoning, even if their fitness for police custody has not been medically assessed.
If a physician finds a person is unfit for police custody, a decision must also be made regarding immediate outpatient or inpatient examination and/or treatment in an acute care hospital. If necessary, the police must ensure further monitoring, even outside the police custody area.
Reimbursement
The state medical association (Landesärztekammer, LÄK) of Saxony (eBox) recommends a reimbursement of €66.50 for a medical assessment in a medical facility and €126.70 for an on-site assessment (i.e., at the site of police custody); for the same services, the Baden-Württemberg medical association recommends a reimbursement of €27.39 and €41.38, respectively, according to the GÖA (German medical fee schedule) for physicians) (3). According to laws that have been in force nine federal states since 2019, the person being detained must bear the costs of police custody himself or herself (13).
Epidemiologic features and risk profiles
Epidemiologic features and risk profiles in Germany have been investigated in multiple studies (10, 14, 15): from Halle (Saale) for the periods 1997–2003 (604 subjects), 2006–2010 (1017 subjects), and 2013–2018 (1271 subjects), from Bremen for 2004–2008 (2053 subjects), and from Frankfurt (Oder) for 2024 (48 subjects).
The age and sex distribution of the examined persons
83.3% of the examined detainees were male In Frankfurt (Oder), 88.7% in Bremen, and over 90.0% in Halle (Saale) in all three periods studied (10, 15, 16). In Frankfurt (Oder). Persons up to age 40 accounted for 65.9% of them in Frankfurt (Oder) and 77.6% to 81.0%, depending on the period studied, in Halle (Saale) (10, 14, 15).
Indications for medical examination in police custody
Acute alcohol intoxication is the most common reason, followed by drug and medication intoxication and the corresponding withdrawal syndromes (Table 1). Traumatic brain injury is the most common type of trauma indicating medical examination in police custody, while the main medical indications are diabetes mellitus, chronic obstructive pulmonary disease (COPD), and hypertension. Further specific indications include alcohol withdrawal syndrome and epilepsy. The main psychiatric indications are acute psychosis and acute endangerment of oneself or others (Table 1) (10, 14, 15).
Determinations of fitness for police custody
Decisions on fitness for police custody varied markedly across regions. 64.6% were assessed as fully fit for police custody In Frankfurt (Oder), but only 32.5% in Bremen (10). In Halle (Saale), the percentage of restricted suitability for police custody with conditions rose over time from 16.7% to 75.4%. The corresponding figures from Bremen and from Frankfurt (Oder) were 55.5% and 22.9%, respectively. The most common recommendation from doctors was to return for a follow-up appointment if the patient‘s condition deteriorated and to undergo close monitoring (Table 2) (10, 14, 15).
The percentage of persons determined to be unfit for police custody and to require inpatient treatment was consistently under 10% in Halle (Saale) (10, 14, 15), 12.5% in Frankfurt (Oder), and 17.2% in Stuttgart (7).
The most common reason for unsuitability for police custody is a mental disturbance or disease (Table 3), the main ones being suicidality, acute psychosis, and agitation with endangerment of oneself or others (10, 14, 15). Severe traumatic brain injury and alcohol intoxication are further common reasons for unsuitability for police custody (Table 3) (10, 14, 15).
Death in police custody
Unlike in other European countries, deaths in police custody are not systematically recorded in Germany (4). A nationwide study of such deaths was conducted for the period 1993–2003 (5). Of the 128 deaths, 60 could be evaluated in more detail. Fifty-nine of the deceased were men, with an average age of 41.1 years. In 23 cases (38.3%), a medical assessment had been carried out beforehand. The most common cause of death was acute alcohol intoxication (25%), followed by drug/medication intoxication, traumatic brain injury (18.3% each), and suicide by hanging (13.3%). Death by natural causes such as pneumonia or myocardial infarction were less common. It was concluded in a retrospective error analysis that 26.6% of these deaths were unavoidable (e.g., myocarditis without prior complaint of symptoms, or fatal cocaine intoxication after ingesting a packet of drugs). In the other cases, death could probably have been prevented by prompt inpatient treatment (5). Alcohol, drug, and medication intoxication also dominate in other European countries, while natural deaths occur more frequently in Asia and North America because of different structures and durations of PG (16). A few years ago, some of the authors intended to conduct a new survey of deaths in Germany, but the requested support from the federal Interior Ministry was denied.
Discussion and recommendations for assessment
The medical aspects of police custody regulations vary widely. It is inexplicable that the police custody regulations in three of the German federal states are held as an official secret and are not available even for scientific evaluation. Knowledge of the applicable regulations is indispensable for the proper assessment of suitability for police custody, not least because changes to these framework conditions can affect the medical determination (17). It follows that doctors and clinics must be provided with the police custody regulations or, at least, with pertinent excerpts.
Indications for consulting a physician and medical responsibility
The official indications for consulting a physician vary across the German federal states and should be harmonized. Indications that medical laypersons will probably not be able to discern (e.g., Saxony-Anhalt: highly contagious infectious diseases) should not be used. In contrast to several neighboring countries, such as Austria and the Netherlands, the medical responsibility for assessing fitness for police custody is largely unregulated in Germany (6, 18). Except in Hamburg, no physician—not even a police or public health doctor—is obliged to carry out such an assessment (19). In the absence of a contractual obligation, the assessment of fitness for police custody can therefore lawfully be refused by a medical on-call service (20) and by doctors on duty in hospital emergency rooms. An assessment cannot be refused if the detainee sustains an actual medical emergency, but such events are rare (14). The responsibility therefore rests with the police to find contract doctors or conclude cooperation agreements with hospitals. In Saxony, for instance, the state medical association provides model cooperation agreements (eBox) that also regulate insurance and liability issues. If such contractual obligations exist, the contracting hospitals must inform the doctors in their employ that this is one of the duties of their position. In the private practice sector, for example, the Saxony Association of Statutory Health Insurance Physicians recommends that its members make a fee agreement with the police if they assess fitness for police custody when they are not legally required to do so (20). If this medical task is undertaken, it is legally considered an expert opinion issued after a physical examination. In such cases, the requirement for medical confidentiality applies only to a limited extent, as the essential medical findings and their consequences are to be passed on to the police.
Nor are there any regulations in Germany at present concerning a specialist standard or special qualification for the assessment of fitness for police custody. In most other European countries, no special qualification is required for this medical activity (6). Only Austria and Moldova have such a requirement; some other countries (e.g., England, France) offer at least some relevant training (6). Given the wide range of indications for assessing fitness for police custody, it is not possible to identify a particularly suitable specialty for this activity. In our view, internal medicine and general medicine can be considered most suitable, as residency training in these disciplines also includes basic treatment and decision-making skills with regard to mental and neurological disorders. The political decision-makers should establish central guidelines on mandatory professional competence. This would mean a specialist standard or a type of specialized training that can be implemented in routine practice.
Type and scope of medical assessment
Another dilemma is presented by the recommendations on the type and scope of the assessment of fitness for police custody. These range from a brief assessment to a symptom-oriented statement to a full physical examination (19, 21, 22). A nationwide survey revealed that 78% of 56 central emergency rooms in Germany have no standard operating procedure (SOP) for evaluating fitness for police custody, and in the self-assessment of examination quality, the mean value was 4.59 points (scale 0–10) (7). Police custody regulations rarely contain specific rules about the type and scope of the examination. Saxony is an exception: the detailed requirements there include current and past medical history (checkbox options), clinical examination (consciousness, pupils, gait, speech, Glasgow Coma Scale, auscultation and abdominal findings), vital signs (blood pressure, heart rate, oxygen saturation, blood sugar, temperature), medication/drug/alcohol history, withdrawal symptoms if any, and signs of mental illness, suicidality, or danger to others. Similar information is required in Baden-Württemberg, where a reporting form now widely accepted as an SOP was developed with the aid of triage specialists from a Stuttgart hospital (3). This SOP by Dengler et al. (7) contains a flowchart for rapid orientation of the treatment pathway and a checklist with documentation of all parameters. A detailed outline of the care pathways for aggressive individuals has been reported from Saxony-Anhalt ([12], eSupplement, eBox), and there are other SOPs at the local level (e.g., at the Krankenhaus der Barmherzigen Brüder, a hospital in Trier).
Symptom-oriented and substance-related assessment
In addition to a general examination, a symptom-oriented assessment is also needed. One of the most common indications in Germany, as elsewhere in Europe, is alcohol intoxication (21). The assessment should address possible additional factors (e.g., the presence of illness or injury) and specific impairments, such as impaired consciousness or orientation (21). Specific cutoff values for alcohol concentration (as a breath alcohol level, where there is such a requirement), e.g., 0.2% in Saxony-Anhalt ([12], eSupplement), cannot be recommended, because alcohol tolerance varies widely. If the individual may have suffered a traumatic brain injury of unclear severity, the corresponding signs and symptoms must be inquired about (mechanism of injury, amnesia, nausea, vomiting, epistaxis, aspiration?). A special consideration in traumatic brain injury is that neurologic impairment may arise only after a variable delay (a “lucid interval”) in persons suffering from a sub- or epidural hematoma. Neurological impairment due to a traumatic brain injury can also be masked by alcohol or drug intoxication. It follows that, whenever such an injury is possible, the individual should be monitored at short intervals or else immediately referred for neurological and radiological assessment.
Aside from substance-use disorders (alcohol, narcotics), other types of mental disturbance are common reasons for assessing fitness for custody that sometimes arouse special concern. The examination should include the ascertainment and documentation of psychopathological symptoms, as is done in general practice and emergency medicine (determination of wakefulness, orientation, affectivity including active questioning about past and present suicidality and self-harming behavior, perceptual disturbances, delusions, anxiety, and compulsive symptoms, along with the use of psychoactive drugs, substance use history, and any evidence of intoxication and foreseeable withdrawal symptoms). Non-psychiatrists assessing psychopathological syndromes, non-psychiatrists can use standardized questionnaires and examination forms, such as the ones used in conjunction with blood/urine samples or in the assessment of mental health and suicide risk on admission to correctional facilities. The standards established there can be a helpful template the development of SOPs for assessing fitness for police custody, as well as for the design of non-medical checks in police custody regulations (23, 24).
Overall assessment and recommendations
The assessment of fitness for police custody is ultimately an individual judgment. The case-by-case risk profile assessment in this situation is analogous, as far as sources of error are concerned, to determinations of the cause of death: there, errors can arise from the non-performance of diagnostic testing, non-admission of an ill person to a hospital, deficient documentation, or inadequate recommendations for monitoring. The main problems with the assessment of fitness for custody by police officers have been found to be failure to consult a physician, inadequate monitoring, and insufficient communication with physicians (8). In real-world practice, situational compromises can be allowed, e.g., the use of digital translation programs or of a (human, professional) interpreter (25). Accompanying persons or relatives can also act as translators in an emergency. Particular documentation may need to be made of the individual’s (in-)ability to communicate. Persons being examined for fitness for police custody are often unwilling or unable to cooperate with the examination; this may limit the examiner’s ability to assess potential injuries and fitness for police custody. Such situations should be documented accordingly, e.g., “An adequate assessment is not possible because…” or “The assessment is significantly limited by…” Depending on the circumstances of the case, the examining physician can protect himself against legal responsibility for a potentially faulty judgment by documenting the individual’s refusal to cooperate and explaining how fitness or unfitness for police custody was nevertheless assessed to the best of the physician’s ability.
Documentation and conditions
The documents from Saxony, Saxony-Anhalt (12) (eSupplement), and Baden-Württemberg (7) also contain guidelines for medical decision-making regarding fitness for police custody and the option of stating further conditions. In Saxony, for example, the physician must determine whether a person is fit for police custody without or with conditions (checkbox options, including free text). A third option is to certify unfitness for police custody, in which case the receiving hospital must be indicated. The use of these three options has proven effective (21) and is also used, for example, in France (18). In further detail, the three possibilities are:
- Fit for police custody: the medical history and physical examination reveal no evidence of current unfitness for police custody (even if a health risk cannot be completely ruled out).
- Fit for police custody under certain conditions: e.g., monitoring every 60 minutes is recommended, or consultation with a specialist is recommended on the following day.
- Unfit for police custody: the medical history and physical examination indicate unfitness for police custody; further outpatient/inpatient diagnostic evaluation and treatment (if needed) are recommended.
In our view, the medical determination of fitness for police custody should be restricted to the maximum duration of police custody without a court order, i.e., 48 hours. Longer police custody by court order requires further assessment of the person‘s fitness for police custody (generally, remanding to a correctional facility) with more extensive history-taking, consideration of prior medical findings, and a detailed physical examination.
Any statement of the medical determination of fitness for police custody and the associated conditions must include the particular mode of monitoring that is recommended and the intervals at which the individual is to be monitored. In comparison to 2005 (11), vague formulations in the legal requirements, such as “appropriate intervals,” have been widely replaced by concrete and often detailed specifications. However, regulations on the qualitative mode of monitoring (e.g., checking whether the person can be awakened or is responsive) are rare. Detailed specifications (e.g., no interruption of the normal sleep phase) should be made known. Medical recommendations are often in need of greater precision. The option of specifications by the physician (e.g., for the administration of food and medication or the need for further diagnostic testing) is more commonly found in the current police regulations than it was in 2005. The equipment in the police custody rooms and the available options for surveillance are important as well. Positive developments since 2005 (11) can be seen in several federal states. In Baden-Württemberg, 73% of police custody cells were equipped with video monitoring equipment by 2019 (3). It should be noted that, even with video surveillance, the checks are not the equivalent of in-hospital monitoring, and only requirements that can be fulfilled by non-physicians can be imposed on police officers.
Overview
Detailed uniform recommendations cannot be made for Germany because of the varying regulations from state to state. Instead, we recommend a step-by-step approach if these assessments are to be conducted by hospitals within the framework of a contractual agreement with the police. In the case of existing contracts, the current practice should be reviewed. First, the police custody regulations of the state in question and any related state-specific documents (examination form, certificate of fitness for police custody, reimbursement) should be looked into. If this is not permitted in full, the police must at least provide excerpts that cover all medical aspects. Next, the medical aspects of the custody regulations and any obligatory documents should be examined critically, in consideration of local conditions and resources. Even though not all federal states currently require written documentation of the current condition and of the medical decision regarding fitness for police custody, the next step should be for the assessing hospital or other body to create its own uniform and structured documents (examination form, certificate of fitness for police custody, reimbursement), with the possible addition of state-specific documents.
Ideally, emergency rooms should develop these documents in collaboration with the responsible police authority, the hospital management or board, and the hospital’s legal department. Local conditions and resources must also be taken into account (e.g., the availability of psychiatric consultation at night). The same applies to the development of an SOP, which is strongly recommended for regular medical assessments of fitness for police custody. A sample flowchart has been developed (Diagram), as a modification and extension of the recommendations of Dengler et al. (7).
Following these recommendations will not eliminate, but will certainly lessen, the judicial risks associated with complications that can arise after an individual has been deemed fit for police custody. Criminal judgments are unlikely even in cases of death, because of the high standard of evidence required by German criminal law (26). The risk of penalties in civil law should be covered by appropriate liability insurance. In view of the federal structures in Germany, a national consensus, such as that in France (27), is probably not possible, but efforts should at least be made to harmonize the applicable state regulations.
Conflict of interest statement
The authors state that they have no conflict of interest.
Manuscript submitted on 30 April 2025, revised version accepted on 27 October 2025.
Translated from the original German by Ethan Taub, M.D.
Corresponding author
Prof. Dr. med. Steffen Heide
steffen.heide@ukdd.de
Department of Legal Medicine, University Hospital Giessen and Marburg, Giessen, Germany.: Prof. Dr. med. Dr. jur. Reinhard Dettmeyer
Department of Emergency Medicine, Barmherzige Brüder Hospital, University Medical Center Mainz, Trier, Germany: Prof. Dr. med. Guido Michels
Police Directorate East (of Brandenburg Police), Frankfurt (Oder): Dr. med. Axel Berg
Clinic and Polyclinic for Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Dresden, Germany: Dr. med. Jan Lange
Institute of Legal Medicine, Faculty of Medicine and University Clinic, University of Cologne, Cologne, Germany: Prof. Dr. med. Markus A. Rothschild
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