Deaths in police custody learning the lessons by sdfsb346f


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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.


    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.

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