Deaths in police custody learning the lessons

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Home Office
Police Research Group
Briefing Note

DEATHS IN POLICE CUSTODY:
Learning the lessons
Adrian Leigh, Graham Johnson, Alan Ingram
Police Research Series Paper 26
July 1998

Background Summary

This research was initiated as a result of continuing Deaths in police custody were found to be rare over the
concern about the number and circumstances of deaths period examined. Between 1990 and 1997, there were an
in police custody on the part of the Police Complaints estimated 3.2 deaths per 100,000 arrests for notifiable
Authority (PCA), the Association of Chief Police Officers offences - although the number of deaths as a proportion
(ACPO), the Association of Police Surgeons (APS) and the of the true number of people passing through police
Home Office. custody could have been much lower.

In total, 380 such deaths were reported to the Home Office The report categorises the 277 deaths into three key
between January 1990 and December 1996. Some cases categories and fifteen sub-categories, according to their
were excluded from the study where police involvement causal factors:
appeared tangential, or so little information was available it
was not possible to establish whether they should be Deceased’s own actions
included. This left 277 deaths for which data were Deliberate self harm (in-custody) 76 (28%)
collected. The main data sources were the files of the Deliberate self harm (pre-custody) 17 (6%)
inquiries conducted by the PCA, force records or Substance abuse (alcohol) 45 (16%)
Coroners’ files.
Substance abuse (drugs) 16 (6%)
Substance abuse (drugs and alcohol) 8 (3%)
The study’s objectives were to gather and examine
Accident whilst police present 10 (4%)
collated information on deaths in police custody in
England and Wales which was not available elsewhere, Total 172 (63%)

and to identify any recurrent common factors which might Deceased’s medical condition
inform changes in police custody practices. The aim was Heart problems 32 (12%)
to highlight general lessons that might help to reduce the Head injuries/problems 27 (10%)
likelihood of deaths occurring in the future, and to
Lung problems 8 (3%)
establish whether the file records might inform the
Epilepsy 4 (1%)
debate about deaths in police custody by providing useful
Liver problems 3 (1%)
insights or raising other issues.
Miscellaneous 7 (3%)

The research findings are subject to a number of Total 81 (29%)
significant caveats which are spelled out fully in the report. Another person’s actions may have been associated
In view of these caveats, the authors point out that care Police actions may have been associated 16 (6%)
should be taken in generalising from exceptional cases. Doctors’ or Medics’ actions may have been associated 3 (1%)
Furthermore, while the study highlights the lessons to be
Other person’s actions may have been associated 3 (1%)
learnt from deaths in police custody, this does not mean
TOTAL 22 (8%)
that all such deaths are avoidable. Sudden deaths do
occur in many circumstances despite the best efforts of TOTAL 275*
those present. Note:*Insufﬁcient data in two cases to establish the causal factors
All percentages have been rounded

A Publication of the Home Office Police Policy Directorate Police Research Group
50 Queen Anne’s Gate London SW1H 9AT
The single most common cause of death was deliberate throughput of drunk detainees, the option warrants further
self harm (DSH), accounting for about a third of cases. serious consideration. Research to establish whether
Substance abuse and medical conditions together detoxification centres are economically justifiable would,
accounted for another half of the deaths. Deaths which however, have to take account of the fact that they require
may have been associated with police restraint a multi-agency approach.
accounted for only 6% of deaths and, in many of these
cases, other potential causal factors also came into play, CCTV and cell design
such as the detainee’s underlying physical and medical The case for CCTV is more complex than it appears at first.
condition, as well as the circumstances of their arrest. CCTV was in place in only a few instances in this study, but
the fact that the detainees went on to die indicated it does
The vast majority (87%) of those dying in police custody not eliminate risk. Nor does it remove the need to check
were white. Although, the proportion of detainees who detainees, or guarantee that everything that happens will
died and were black exceeded the proportion of black be noted by custody staff. Nevertheless, its greatest
people in the general population, this could partly be benefit may be in the early detection of detainees who
explained by their proportionately higher number of collapse from a medical condition or are trying to harm
arrests. This apparent over-representation of deaths of themselves. The cost of having CCTV in all the cells,
black detainees as a proportion of those arrested could however, may prove prohibitive and the positioning of the
also be explained by the higher rate of deaths common to cameras could have privacy implications.
all ethnic groups in the Metropolitan Police Service area,
where the most arrests and deaths of black people One option may be to have CCTV in one or two cells
took place. The numbers, however, were too small for designated for ‘at risk’ detainees, This, however,
any definite conclusions to be drawn. Although not presupposes that officers can accurately identify ‘at risk’
statistically significant, there also may have been a detainees at an early stage: this study demonstrates that
difference between the ways in which white and black this is not always straightforward. Forces may also be able
detainees died. There were various possible explanations to draw on some of the lessons emerging from recent
for this difference, but the available data could not resolve, studies in the Prison Service to design ‘safe cells’.
which, if any, of these explanations was most valid.

The authors highlight several possible future initiatives
Points for action
which could not be covered by this research or emerged
as issues during data analysis: Health and behaviour checks
Medical training for civilian and officer custody staff q On several occasions, serious head injuries were
Although other recent studies have found that custody interpreted as drunkenness by officers, ambulance
staff have received little in the way of medical training, crews or police surgeons. Several symptoms of
there were many examples in this study of officers drunkenness appeared particularly relevant: there
apparently attempting resuscitation. It is important that were cases where detainees had to be carried to
custody staff have practical medical knowledge and can their cell, were insensible, vomiting frequently or
apply basic first aid, or have quick and easy access to snoring heavily. Custody staff need to be aware
someone who can. As to whether custody staff should that in some cases, these symptoms may reflect a
receive more advanced medical training, there are a medical condition or injury.
number of complex issues requiring further consideration. q Given the high rate of suicide deaths, custody staff
These issues include, in particular, whether it would be
should be particularly alert to statements of suicidal
better for custody staff to receive additional training
intent. In addition, some detainees had packets of
in how to identify early warning signals so that they can
drugs or medicines in their possession. It is important
call for medical help earlier. Furthermore, officers might
that detainees are searched effectively, that officers
benefit from guidance on what signals they should be
take note of any medications on them, and that this
looking for when “rousing” detainees.
information is passed to the police surgeon. Two of
One option might be the development of protocols, based the reports’ authors developed a checklist to help
on the detainee’s level of consciousness, to help officers custody staff identify detainees who may be at risk
decide whether a detainee needs professional medical of deliberate self harm (DSH). This checklist is
attention. The APS and PCA were considering this reproduced on the last page of this briefing note.
possibility whilst this study was underway. q Where there are concerns about a detainee’s health
Detoxification and drying out centres and behaviour, it is important they are checked
frequently, particularly at the start of their detention
A large number of people pass through the system under when their condition may be an unknown quantity.
the influence of alcohol. Frequently, they have been Also, more formal checks should be run on detainees
arrested not to protect the public but for their own safety. coming into custody, such as carrying out Police
Many of these people may actually need a degree of low National Computer (PNC) checks. Although these
level medical care while they are “sleeping it off”. may provide only a rough indicator of potential
Furthermore, there will be cases where apparent problems, if such checks are not carried out and a
drunkenness masks more serious conditions. The issue of death occurs the police cannot demonstrate that they
detoxification centres is not new but, to date, only a few have followed the proper procedures.
such centres exist. For forces experiencing a large
Completion of official records individuals or procedures were ‘at fault’. However, as
there is potential here for detainees to be put at risk,
q The authors could not always identify with certainty efforts should be made to minimise the danger of
the actions taken because custody records were only communication failures.
partially complete. There were also instances where it
appeared that the required forms (POL1s) had not Restraint
been completed to record apparent warning signals.
q The presence of drugs may have played a part
It would help to inform the future treatment of
in some of the deaths with which police restraint may
detainees if the completion of POL1s by custody
have been associated - by increasing the person’s
officers automatically led to an entry on the PNC. The readiness to resist arrest and/or reducing their
planned introduction of the Prisoner Escort Record susceptibility to pain. In many of these cases,
(PER) form should help to ensure regular assessment detainees were recorded as reacting violently to
of detainees, provided communication is effective. arrest. Such a reaction may place a detainee at
greater risk. Furthermore, the combination of the way
q The reports produced by Investigating Officers (IOs) in which the detainee was held after arrest and other
following a death in custody varied considerably in factors such as their size, medical condition, earlier
content and detail. IOs seldom recorded whether physical exertion, or consumption of drugs or
officers had received restraint training, even where alcohol, featured in many of the deaths. The concept
restraint was relevant as a possible cause of death. that restraint and position alone can lead to death has
The service should, therefore, give some thought to been challenged by recent research. Additional
introducing “minimum standards” for IO reports, and factors did indeed appear also to have contributed to
most deaths where position and restraint were issues.
guidance on their contents.
q Forces should ensure that officers are aware of these
Communication dangers and receive the required level of restraint
training when they join and later in their careers. An
q There were occasional lapses in the communication important recent development has been the
amongst officers, doctors, and medics (such as ACPO/National Police Training Personal Safety
ambulance crews). It was not possible to assess how Programme, which includes coverage of positional
common such lapses were in general, nor whether asphyxiation and excitable delirium. Training should
also make officers aware of how best to handle
situations where a detainee attempts to escape.

Other related PRG publications:

Ingram, A. and Johnson, G. (1997) Self Harm and Suicide by Detained Persons:
A Study, Police Research Award Scheme Paper, London: Home Office Police Research Group.

Ingram, A. and Johnson, G (1998) Self Harm and Suicide by Detained Persons:
An Information Booklet for Police Custody Staff, London: Home Office Police Research Group.

Note:

Deliberate self harm (DSH) was the most common cause of deaths in police custody. A checklist, developed by two
of the reports’ authors to help custody staff to prevent such incidents, is reproduced overleaf. This checklist is taken
from Ingram A, and Johnson, G. (1998) Self Harm and Suicide by Detained Persons: An Information Booklet for Police
Custody Staff, London: Home Office Police Research Group. This booklet was produced, in conjunction with Principal
Officer Ian Heyes of HMP Garth, as a result of a project arising from an award made by the Police Research Award
Scheme in 1996.
WHY NOT CHECK?

Who are you receiving into your custody?
• Before you place a detained person in a cell it is your duty to find out who you are dealing with.
• And to ensure that they are fit to be detained.

History: what can you find out about the detained person?
• Do a PNC/Phoenix check.
• Are there any information markers?
• What further information can you find out?
• Do you know the detained person?
• Does the arresting officer know them?
• If there is no known history, ask: “Have you ever deliberately harmed yourself whilst in custody?”

You are responsible for the care of the detained person
• PACE and the Codes of Practice specify your statutory responsibilities and the circumstances when you must
immediately call the police surgeon or, in urgent cases, send the person to hospital.

Note changes in conduct, mood and what they say
• Persons with suicidal tendencies may change their conduct - were they loud but now quiet? Were they
subdued but now exuberant? Why?
• Has their mood changed? Are they now happy, relaxed, at peace with themselves?
• What are they saying? “Nobody cares about me anymore!”, “I’ve nothing to live for”.

Observe - visit them at frequent but irregular intervals
• The Codes of Practice state “people detained shall be visited every hour”, “those who are drunk, at least every
half hour, and they shall be roused and spoken to on each visit”.
• You can decide to visit those ‘at risk’ more frequently: this usually means leaving no longer than 15 minutes
between visits or considering a constant watch.
• Make visits irregular: it stops detainees planning ‘the right moment’ and reduces their opportunities.

Tell someone else
• A Prisoner Escort Record (PER), replacing the old POL1 form, will be completed by police, prisons and escort
services for all people in custody.
• Make sure the PER is part of the custody record.
• Make sure a copy of the PER is given to other agencies accepting responsibility for the detainee.
• Voice your concerns - don’t keep them to yourself.
• Inform PNC/Phoenix to record and update an information marker.

Cell - safety and condition
• Is the cell safe for a detainee to be left alone in?
• Ensure there are no ‘fixing points’ for ligatures.
• Is the cell damaged? Damaged areas can provide the means for DSH.

Hatch or wicket to remain shut
• The cell hatch (or wicket) is used by most detainees who DSH.
• If the cell is occupied shut the hatch wherever and whenever possible.
• Make sure the inside of the door is safe and that the hatch fits properly.

Enquire into detainees’ welfare
• If you are concerned about a detainee, talk to them: make them feel you care.

Custody record accuracy
• The custody record must fully reflect all that happens.
• Record all visits and time them accurately.
• Make full records of police surgeon visits and instructions.

Knowledge helps all
• Know who it is you are dealing with.
• Tell PNC/Phoenix for your colleagues benefit.
• Complete the PER form: the information you record protects the detainee and you.

Papers in the Police Research Group Crime Prevention Unit, Crime Detection & Prevention Series, Police Research Series,
Special Interest Series and other PRG ad hoc publications are available free of charge from:
Home Office, Police Research Group Publications, Room 455, 50 Queen Anne's Gate, London, SW1H 9AT.
Facsimile no. 0171 273 4001.