1998 uk home office - deaths in custody lessons

7/26/2019 1998 UK Home Office - Deaths in Custody Lessons

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Police Research SeriesPaper 26

Deaths in Police Custody:

Learning the Lessons

Adrian Leigh

Graham Johnson

Alan Ingram

Ed i t o r:DrG.Laycock Home Ofic e

Po l i c e

R e se arc h

Group50Quee!e"sGate


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C CrownCopyright1998FirstPublished1998

PoliceResearchGroup:PoliceResearchSeries

TheHomeOfcePoliceResearchroup!PR"was#ormedin199$tocarryout andmanageresearchinthesocialandmanagementsciencesrele%ant

to

the

wor& o#

the

police

ser%ice' The

terms

o#

re#erence

#or

the

roup

include

the re(uirement

to

increase

the

in)uence

o#

research

and

de%elopment

wor&

on

police policyandpractice'

*&eyareao#wororthegroupisidenti#yinganddisseminatinggoodpolicing practice' Theaimo#thePoliceResearch+eriesistopresentresultso#e,ternally #undedstudiesandthosecarriedoutbythePoliceResearchroup-inawaythat willin#ormpolicyandpracticethroughoutthepoliceser%ice'

*parallelserieso#papersoncrimepre%entionisalsopublishedbyPR-asisa periodicalonpolicingresearchcalled.Focus/'

ISBN1-84082-122-1

*o p i e so +thi spu,licatio ca ,e made a-ai la,l ei +o rm atsacc essi , l e to th e-i sual lyim pai redo re. ue st.


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Foreword

*nydeathinpolicecustodyisatragicanddistressinge%ent#orallconcerned'Thisstudydrawsontheofcialrecords#romin(uiriesinto$00suchdeathswhich occurredbetween1anuary1992and3ecember1994-toestablishwhatgeneral lessonsmightbedrawntohelpa%oid#uturedeaths'

Thestudy5ndsthat-ta&ingacounto#thenumbersarrestedorpassingthrough policecustody-deathswererare' 6nmanycases-theywerealsonotob%iouslypre%entable' 6nthema7orityo#cases-detaineeshadeitherdeliberatelyharmed themsel%esorsu8eredthe#atalconse(uenceso#apre9e,istingmedicalconditionwhilstincustody' 6nasigni5cantnumbero#othercases-detaineesdied#romthe e8ectso#abusingsubstancessuchasalcoholordrugs' 6nallo#thesecases-the potentiallessonsin%ol%ethepoliceandmedicalpro#essionbeingabletodetect earlywarningsignalsandreactingtothem(uic&lyandcorrectly'

6nasmallnumbero#casestheactionso#someoneelsemayha%ebeenassociated withthedetainee/sdeath' 6nsi,teencases!4:o#allthedeathse,amined"police actionsmayha%ebeensoassociated' Thelessonstobelearnedhererelatelargely tohowtheofcersshouldbestapplyrestraintgi%enthe

circumstancesand apparentconditiono#thedetaineeatthetime'

;ongerterm-the&eyissuesthatemerge#romthestudyincludetheneed#or#urther considerationo#deto,i5cationcentres-themedicaltrainingo#custodysta8andissuessurroundingtheuseo#CCT


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$c%&owled'e(e&)s

=ewouldli&etothan&allthosewhocontributedtothisresearch>

all

the

police

#orces

in

?ngland

and

=ales

who

agreed

to

ma&e

their

records a%ailable

the*ssociationo#Chie#PoliceOfcers

Her@a7esty/s6nspectorateo#Constabulary

thePoliceComplaints*uthority

*ssistantCommissioner3unn-3r;ewingtonand3etecti%e+ergeantAridgeman o#the@etropolitanPolice+er%ice

theCoronerscontactedduringthedatacollection

the*ssociationo#Police+urgeons

3rraham?Coo&o#The@idBentHealthcareTrust

ationalPoliceTraining

theChie#Constableo#;ancashire-whoagreedtoma&e6nspectors6ngramand1ohnsona%ailabletocollectthedatathat#ormedthebasis#orthereport'

=ewouldalsoli&etothan&1aneHirst!whowasresponsible#ormucho#the groundwor&"and1ennieThorpeo#PR#ortheirassistance' Ourparticularthan&sgoto1onathanichollsinthePoliceResearchroup-whosecontributionata criticalstageo#thepro7ectpro%edin%aluable'

"he$u)hors

*drian;eighisaseniorresearcherwiththePoliceResearchroup' *lan6ngram andraham1ohnsonareboth6nspectorsinthe;ancashireConstabulary'

PRwouldli&etothan&Pro#essorPaul=ilesattheDni%ersityo#+hefeld#or actingasindependentassessor#orthisreport'


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*+ecu)i,eSu((ar

Thisresearchwasinitiatedasaresulto#continuingconcernaboutthenumberand circumstanceso#deathsinpolicecustodyontheparto#thePoliceComplaints *uthority!PC*"-the*ssociationo#Chie#PoliceOfcers!*CPO"-the *ssociationo#Police+urgeons!*P+"andtheHomeOfce'

6ntotal-.80 suchdeathswerereportedtotheHomeOfcebetween1anuary1992 and3ecember1994' O#these-wee,cluded#romourstudycaseswherepolice in%ol%ementappearedtangential-orsolittlein#ormationwasa%ailablewecould notestablishwhethertheyshouldbeincluded' Thisle#t2//deaths#orwhichwe collecteddataandcompiledadatabase' Themaindatasourceswerethe5leso# thein(uiriesconductedbythePC*-#orcerecordsorCoroners/5les'

Thestudy/sob7ecti%esweretogatherande,aminecollatedin#ormationondeaths inpolicecustodyin?nglandand=aleswhichwasnota%ailableelsewhere-andto identi#yanyrecur rentcommon#actorswhichmightin#ormchangesinpolice custodypractices' 6twasnotaboutapportioning.blame/-butabout

highlighting 1ee ral lessonsthatmighthelptoreducetheli&elihoodo#deathsoccurringinthe #uture' =ealsohopedthatthedatawecollectedwouldhelptoin#ormthedebate aboutdeathsinpolicecustody' =edido te,pecttobeabletoanswerallthe (uestionswiththein#ormationwegathered#romthe5les'Ouraimwasto establishwhethertherecordspro%idedanyuse#ulinsightsorraisedotherissues whichmightbeconsideredinthe#uture'

*lthoughtheresearchaddressedawiderangeo#issuesdrawing#romaconsiderable %olumeo#data#romalargenumbero#cases-the5ndingsaresub7ecttothe#ollowingca%eats>

=ecouldnote,aminecaseswheredetaineesweresa-e dbytheactionso# ofcers-custodyormedicalsta8' Furthermore-inmostinstances-wecould

not comparethecircumstanceso#thepeoplewhodiedincustodywiththoseo#al l thepeoplewhohadpassedthroughcustody-becausecomparabledata#orthe custodialpopulationwereuna%ailable'

Theresearchwasnecessarilyretrospecti%eand-becauseo#di8eringstandardsin reportingprocedures-therewerenumerousgapsinthein#ormationoriginally

recordedandcollected-sometimesresultinginincompletedata' 6naddition-the a%ailablerecordshadnotbeenwrittenwith#utureresearchneedsinmind-butas parto#thein%estigati%eprocess#ollowingadeath'


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Thedatacollectionwasprimarily#romthe5lesmadea%ailabletous'6twas beyondthescopeo#thisstudytoreconsiderthecircumstanceso#eachdeath-and any(ualitati%edataweredrawn#romthesummariesandnotesattachedtothe case5les'6naddition-therecordsweusedtoldtheo fic i al accounto#whathappenedEinsomecases-otherpartiesmaydisputethataccount'

*sthedeathswee,aminedwereso#ewanddispersedEbothgeographicallyand o%ertimeEitwaso#tendifculttoidenti#ystatisticallysigni5cant5ndings

!althoughthisdidnot-o#course-pre%entus#romdrawingoutpossiblelessons whichseemedtoemerge#romthecases"'

=ecoulddraw #ewconclusionsaboutthe(ualityo#careandthecustodypractices 1e e ral lye,hibitedbythepolice' +omecasesre)ectedsituations whereerrorsmay ha%ebeen made-butwehadnoway o#&nowingwhetherthesere)ectedunderlyingproblems inthetreatmento#detainees-orwhether they were occasionallapsesinasystemthatgenerallywor&edwell'Furthermore-i#therewereoccasionallapses- thisstudycouldnotestablishho2o +te theyoccurred'

Theseca%eatsmeanthatcareshouldbeta&eningeneralising#rome,ceptional cases>whatappearstobeause#ullesson#romonecasemaynotbeappropriateor realistici#appliedacrosstheboard'

"hepa))er&o0dea)hsi&policecus)od

3eathsinpolicecustodywererareo%ertheperiodwee,amined' Aetween1992 and1990-therewereanestimatedF'$deathsper122-222arrests#ornoti5able o8encesEalthoughthenumbero#deathsasaproportiono#thetruenumbero# peoplepassingthrough policecustodycouldha%ebeenmuchlower'

Thereportcategorisesthe$00deathsintothree&eycategoriesaccordingtotheir causal#actors>

Causal#actor umber o#deaths1 :

o#alldeaths

3eceased/sownactions 10$ 4F:

3eceased/smedicalcondition 81 $9:

*notherperson/sactionsmayha%ebeenassociated $$ 8:

ote>1 Thedataintwocaseswereinsufcienttoenablecategorisation'


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=ithinthesethree&eycategories-weidenti5ed5#teensub9categoriestoaid analysiso#thedeaths' Thesinglemostcommoncauseo#deathwasdeliberatesel#harm!3+H"-accounting#oraboutathirdo#cases'+ubstanceabuseandmedical conditionstogetheraccounted#oranotherhal#o#thedeaths' 3eathsthatmay ha%ebeenassociatedwithpolicerestraint-accounted#oronly4:o#deathsand-in manyo#thesecases-otherpotentialcausal#actorsalsocameintoplay'These

#actorsincludedthedetainee/sunderlyingphysicalandmedicalcondition-aswell asthecircumstanceso#theirarrest'

The%astma7ority!80:"o#thosedyinginpolicecustodywerewhite'*lthough- theproportiono#detaineeswhodiedandwereblac&e,ceededtheproportiono# blac&peopleinthegeneralpopulation-thiscouldpartlybee,plainedbytheir proportionatelyhighernumbero#arrests'*napparento%er9representationacross all#orceso#deathso#blac&detaineesasaproportiono#thosearrestedcouldalsobe e,plainedbythehigherrateo#deathscommontoal lethnicgroupsinthe@etropolitanPolice+er%icearea-wherethemostarrestsanddeathso#blac&people too&place'Thenumbers-howe%er-weretoosmall#oranyde5niteconclusionstobedrawn' *lthoughnotstatisticallysigni5cant-therealsomayha%ebeena di8erencebetweenthewaysinwhichwhiteandblac&detaineesdied'Therewere

%ariouspossiblee,planations#orthisdi8erence-butthea%ailabledatacouldnot resol%ewhich-i#any-o#thesee,planationswasmost%alid'

Goodprac)icelesso&sa&dreco((e&da)io&s

+omeo#the&eyrecurringthemesemerging#romouranalysiso#the$00deathsare listedbelow'

He al thad ,e h a- io urc h ec ks

Onse%eraloccasions-seriousheadin7urieswereinterpretedasdrun&ennessby ofcers-ambulancecrewsorpolicesurgeons' Thesedetaineeswereprocessedasdrun&s-ratherthangettingthemedicalattentiontheyneeded' Furthermore- se%eralsymptomso#drun&ennessappearedparticularlyrele%ant' Therewerecases

wheredetaineeshadtobecarriedtotheircell-wereinsensible-%omiting#re(uently orsnoringhea%ily' Custodysta8needtobeawarethatinsomecases-thesesymptomsmayre)ectamedicalconditionorin7ury'

i%enthehighrateo#deathsby3+H-custodysta8shouldbeparticularlyalertto statementso#suicidalintent' 6naddition-somedetaineeshadpac&etso#drugsor medicinesintheirpossession'6tisimportantthatdetaineesaresearchede8ecti%ely- thatofcersta&enoteo#anymedicationsonthem-andthatthisin#ormationis passedtothepolicesurgeon'


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=herethereareconcernsaboutadetainee/shealthandbeha%iour-itisimportant theyarechec&ed#re(uently-particularlyatthestarto#theirdetention-whentheir conditionmaybeanun&nown(uantity' *lso-more#ormalchec&sshouldberun ondetaineescomingintocustody-suchascarryingoutPoliceationalComputer !PC"chec&s' *lthoughthesemaypro%ideonlyaroughindicatoro#potential problems-i#suchchec&sarenotcarriedoutandadeathoccursthepolicecannot demonstratethatthey#ollowedtheproperprocedures'

*o m p l e t i o

o +

o fic i al

rec o rd s

The%alueo#runningchec&sondetainees/recordsisunderminedi#thesearenot #ullymaintained'Therewereoccasionswhenwecouldnotidenti#ywithcertainty theactionsta&enbecausecustodyrecordswereonlypartiallycomplete'Therewere alsoinstanceswhereitappearedthatthere(uired#orms!PO;1s"hadnotbeen completedtorecordapparentwarningsignals'6twouldhelptoin#ormthe#uture treatmento#detaineesi#thecompletiono#PO;1sbycustodyofcersautomatically ledtoanentryonthePC'Theplannedintroduction o#thePrisoner?scort Record!P?R"#ormshouldhelptoensureregularassessmento#detainees-butits impactcouldbehamperedi#communicationisine8ecti%e'

Thereportsproducedby6n%estigatingOfcers!6Os"#ollowingadeathincustody %ariedconsiderablyincontentanddetail>ina#ewcasesthereportwasnolonger thanonesideo#*G' Poordata-#orinstance-meantthatwehadtoe,clude thirteencasesbecausewecouldnot7udgewhethertheymetourcriteria#or inclusion' 6Osseldomrecordedwhetherofcershadrecei%edrestrainttraining- e%enwhererestraintwasrele%antasapossiblecauseo#death'Theser%iceshould- there#ore-gi%esomethoughttointroducingminimumstandardsI#or6Oreports- andguidanceontheircontents'

*om muicat i o

Therewereoccasionallapsesinthecommunicationamongstofcers-doctorsand medics!suchasambulancecrews"'=ecouldnotassesshowcommonsuchlapses wereingeneral-norwhetherindi%idualsorprocedureswere.at#ault/'Howe%er-as thereispotentialhere#ordetaineestobeputatris&-e8ortsshould

bemadeto minimisethedangero#communication#ailures'

R estrait

Thepresenceo#drugsmayha%eplayedapartinsomeo#thedeathswithwhich policerestraintmayha%ebeenassociatedEbyincreasingtheperson/sreadinessto resistarrestandJorreducingtheirsusceptibilitytopain' 6nmanyo#thesecases-


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detaineeswererecordedasreacting%iolentlytoarrest'+uchareactionmayplacea detaineeatgreaterris&whilstofcersrestrainthem-andoncetheyha%ebeenrestrained'Furthermore-thec o m, i ati o o#thewayinwhichthedetaineewasheld a#terarrestand ot h e r+act o rssuchastheirsiKe-medicalcondition-earlierphysicale,ertion-orconsumptiono#drugsoralcohol-#eaturedinmanyo#thedeathswhere restraintmayha%ebeena#actor' Theconceptthatrestraintandpositional o ecan leadtodeathhasbeenchallengedbyrecentresearch-andtheseadditional#actors didindeedappearalsotoha%econtributedtomostdeathswhere

positionand restraintwereissues'

Forcesshouldensurethatofcersareawareo#thesedangersandrecei%ethe re(uiredle%elo#restrainttrainingwhenthey7oin-andre#reshertrainingatregular inter%alsor#orimportantde%elopmentsinrestrainttraining' *nimportantrecent de%elopmenthasbeenthe*CPOJationalPoliceTrainingPersonal+a#ety Programme-whichincludesco%erageo#positionalasphy,iationande,citable delirium' Thepolicealsoneedtobealerttothe#actthatdetaineesattempting escapemayplacetheirli%esindanger-andtrainingshouldma&eofcersawareo# howbesttohandlesuchsituations'

Possi1lewas0orwar d

+e%eralpossible#utureinitiati%eswereconsideredduringthisstudyLthesearose either asinitial(uestions o#thisresearch-orasissuesthateme rgedduringthedataanalysis>

4e d i c altrai i 1+o rc i - i l i aad o fic e rc usto dy+sta+

Otherrecentstudiesha%e#oundthatcustodysta8ha%erecei%edlittleinthewayo# medicaltraining-althoughthereweremanye,amplesinourstudyo#ofcersapparentlyattemptingtoapply5rstaidorresuscitation'6tiscertainlyimportant thatcustodysta8ha%epracticalmedical&nowledgeandcanapplybasic5rstaid-orha%e(uic&andeasyaccesstosomeonewhocan' *stowhethercustodysta##shouldrecei%emoread%ancedmedicaltraining-thereareanumbero#comple, issuesre(uiring#urtherconsideration' Theseissuesinclude-inparticular-whether it

wouldbebetter#orcustodysta8torecei%eadditionaltraininginhowtoidenti#y earlywarningsignalssothattheycancall#ormedicalhelpearlier'Furthermore-ofcerscouldbene5t#romguidanceonwhatsignalstheyshouldbeloo&ing#or whenrousingdetainees'

Oneoptionmightbethede%elopmento#protocolsbasedonthedetainee/sle%elo# consciousness'=ewereaware-duringthisresearch-thatthe*P+andPC*were consideringthispossibility'+uchprotocolsshouldaimtohelpofcersdecide whetheradetaineeneedspro#essionalmedicalattention-ratherthane8ecti%ely re(uiringcustodysta8topro%idea#ullmedicaldiagnosis'


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2o&)e&)s

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Forewor

d !iii"$c%&owled'e(e&)s !i%"

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1 I&)roduc)io& 1

3ealingwithdeathsinpolicecustody 1Thebac&groundtothereport $Thereport/smethodology $Thepurposeo#thereportanditslimitations GThestructureo#thereport 0

22a)e'orisi&')hedea)hs 8

=hodiedwhereandwhenM 8Categorisingthedeaths>causal#actors 9

."hedeceased5sow&ac)io&s6deli1era)e sel0har ( 1.

6denti#yingthedeathsby3+H 1F=arningsignsatthepointo#detention 1GTa&ingthesuspectsintocustody 19Chec&ingdetaineeswhilstincustody $2Policeactionsondisco%ering3+Hdeaths $1


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4"hedeceased5sow&ac)io&s6su1s)a&ce a1usea&daccide&)s

Pa'e

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+ubstanceabuse $F

=arningsignsatthepointo#detention $GChec&ingdetaineeswhilstincustody $4Policeactionsondisco%eringsubstanceabusedeaths $8*ccidentswhilstthepolicewerepresent F2

7"hedeceased5s (edicalco&di)io& .2

=arningsignsatthepointo#detention FF

Chec&ingdetaineeswhilstincustody F4Policeactionsondisco%eringdetaineesindifculty F8

Waspoliceres)rai&)a0ac)or9 40

3eathsthatmayha%ebeenassociatedwithotherpeople/sactions G23eathsthatmayha%ebeenassociatedwithpolicerestraint G1How#re(uentlydidthepoliceuserestraintM G1=hattypeso#restraintwereemployedandwhenM GF

=henandwhywaspolicerestraintassociatedwiththedeathsM GG;essons#romthecaseso#restraint#ailure G0=hatrestrainttraininghadofcersrecei%edM G9

/ea)hsa&d)hee)h&ici)o0)hede)ai&ees 71

3eathsandethnicity N1Comparingwhiteandethnicminoritydeaths N$

=ereethnicminoritieso%er9representedamongstthedeathsincustodyM NFHowdiddetainees#romethnicminoritiesdieM N8Conclusions 4$


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8Wha)were)heac)io&so0)hedoc)orsa&d(edics9

Pa'e

4

@edicalattentionbe#orecustody 4G@edicalattentiononceincustody 4NHowlongdidtheF@?sta&etoarri%eM 44=hatdidtheF@?sad%iseM 403+Hdeaths>medicalin%ol%ement 48+ubstanceabusedeaths>medicalin%ol%ement 023eaths#rommedicalconditions>medicalin%ol%ement 023eathsassociatedwiththeF@?s/actions 0$OfcersandF@?s>lessonsincommunication 0$

;2o&clusio&sa&dreco((e&da)io&s:)helesso&s)o1elear&ed /7

Thepatterno#deathsinpolicecustody 0Noodpracticelessonsandrecommendations 04Possibleways#orward 09?ndnote 8F

Re0ere&ces 84

$ppe&di+1: 2aseswherepoliceac)io&s(aha,e1ee&associa)ed wi)h)hedea)h8

$ppe&di+2: *)h&icclassi0ica)io&i&)herepor ) 88

$ppe&di+.: *+pla&a)io&o0)hecalcula)io&su&derli&'"a1le20 8;

Rece&)PoliceResearch

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3is)o0"a1les

"a1leNo

1

2ap)io&

Beycharacteristicso#thosewhodied!oursampleo#$00"

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$ Reasons#orar rest 9

F Causal#actors>deathsinpolicecustody-19921994!oursample"

11

G 3+Hwarningsignsandbeha%iouralsignalswhen thedetaineeswereta&enintocustody 1N

N The0Fin9custody3+Hdeathsbyhanging>ligaturesand5,turesused

19

4 The9F3+Hdeaths>#re(uencyo#chec&s $2

0 ;ocationo#3+Hdeaths $1

8 The49substanceabusecases>treatmentincustody $N

9 The49substanceabusecases>#re(uencyo#chec&s $0

12 +ubstanceabusecases>recordedpoliceactionson5nding detaineesdeadorcollapsed $9

11 The49substanceabusecases>locationo#death $9

1$ The81deaths#rommedicalconditions>&eycharacteristicso#thedeceased

FF

1F 36detaineeswhodied#romheadin7uries FG

1G 6mmediatedecisionsaboutill9healthdetainees F4

1N The81deaths#rommedicalconditions>#re(uencyo#chec&s F4

14 ;ocationo#deathsresulting#romdetainee/smedicalcondition F9

10 Theuseo#restraintonarrestandreason#orarrest- ran&edby#re(uencyo#use G$

18

The

ethnicity

o#

detainees

dying

in

police

custody>19921994 !our

sample"

N1

19 Reason#orarrestbyethnicgroup NF

$2 ?stimateddeathsper122-222arrests#ornoti5ableo8ences>ethnicbrea&down

N4

$1 ?thnicityandthecauseo#death N8

$$ ?thnicity-whetherthedetaineeresistedar restandwhether theyhadta&endrugs 4$

$F Reasonswhythepolicecalled#oranF@? 4N

$G F@?s>call9outsperdetainee 44

$N F@?s/ad%ice 48

$4 3eaths#rommedicalconditions>F@?s/opinions 02


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3is)o0Bo+ es

Bo+No

1

2ap)io&

The*ppendi,N$de5nitiono#deathsinpolicecustody

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F

orotherwisewiththepolice

$ 3+Hcaseswithbeha%iouralwarningsignals 18

F *ccidentswhilstthepolicewerepresent F1G 3eathsassociatedwithotherpeople/sactions G2

N Policeuseo#physicalrestraint GF4

0

?thnicminoritydeaths>policeactionsandaccidents whereofcerswerepresent3etaineeswhodied#romheadin7uriesdespite

N9

4N

beingseenbymedics

8 3+HwarningsignsandF@?s 49

9 F@?/sactionsassociatedwiththedeaths 0$

3is)o0Fi'uresFi'ureNo 2ap)io& Pa'e

1 @edicalconditionsasthe&eycauseo#death F$$ Caseswherepoliceactionsmayha%econtributed GN tothedetainee/sdeath


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6TRO3DCT6O

1 I&)roduc)io&

eali&'wi)hdea)hsi&policecus)od

Thepolicearee,pectedtodetainindi%idualstheybelie%etoha%ebro&enthelaw' Howe%er-theyalsoha%eadutytoprotectanyindi%idualtheyha%earrestedor detained#ortheirownsa#ety' 6tisthisdualresponsibilitythatma&esanydeathin policecustodydisturbingandpotentiallycontro%ersial' For#amilieso#thedeceaseditcanbeparticularlydistressingtolearnnotonlythatsomeonetheywere closetohasdied-butalsothatthishappenedwhilsttheywereinpolicecustody'Forthepoliceofcersin%ol%ed-thedeathitsel#willha%ebeentraumaticandthe resultingin(uiriesareli&elytoplacethemunderintensepersonalpressure'

6nadditiontothehumantragedy-e%erydeathincustodyplacesanimmense burdenonthepoliceandtheotheragenciesthatbecomein%ol%edinin%estigating thecircumstances' Theperiod#romthedeathtothecompletiono#in(uiries%aries withthecircumstancesbut#re(uentlylastsmonthsore%enyears-asthe&eystages- describedbelow-arepassed'

6mmediatelya#ter5ndinganindi%idualapparentlydeadordyingincustody-the policemustattemptresuscitationandcall#ormedicalhelp'Ofcersshouldcontinuetoattemptresuscitationuntilthepersonista&entohospitalorcerti5ed asdeadbya(uali5edperson'

*#tersecuringthesceneandcustodyrecords-#orcesad%isetheCoronero#the death-appointan6n%estigatingOfcer!6O"-andusuallyin#ormthePoliceComplaints*uthority!PC*"1' Forcesmustalsoin#ormtheOperational PolicingPolicyDnito#theHomeOfceandH@6nspectorateo#Constabulary!H@6C"withinG8hourso#thedeath'

TheCoroner/spathologist!s"conductsapost9morteme,aminationtoestablish thecauseo#death-whilstthe6Oin%estigatesthecircumstancesleadinguptothe death' 6Oso#tenaimtocompletetheirin%estigations-whichincludere%iewing allrele%antrecordsandinter%iewingwitnesses-within#ourmonths'

Oncethe6Ohas comp letedthei rin%est igation!usuallyunderPC* super%ision"-theyp ro%idethei r#indingsas e%idence totheCoronerand- i#app ropr ia te-to theCrown Prosec ution+er%ice!CP+"' The Coronerthen holds an in(uest-be#ore a 7u ry-toreacha %e rd ic t!thisin(uestdoesnotsee& toestablishindi%idua lb lame#ora death"' 6# theCP+ decidetobr ing cr iminalcha rges -the Coronerad7ourns thein(uestunt i lthecr iminalprocess has beencomp le ted'=heretheCP+ decide notto bring c rim inalcharges- theymayre% iewthat decision i# theCoroner/s7uryreturnsa %e rd ict!suc has.u l a2+ulkil l i /1"suggest ingc riminalchargescould be app ropriate'

%De ath si police custo dyear -o l utari lyre +erredto th e

P*! ,y+o rce sude rsectio o +P!*E.6 th ee arly

%&&0s7th e ma8o ri tyo +de ath s2e re o t re +e rred,u t7

sice th i st i m e7 +o rce sh a-ei c re asi 1 lyre +reerd de ath s

automati c al lyso th atal l suc hde ath sare o 2usual ly

re +e rred .


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3ependingontheoutcomeo#thein(uiryorCP+prosecution-thePC*then decidewhethertorecommendthatthe#orceholdadisciplinaryhearing'

uiteapart#romthehumancost-there#ore-deathsinpolicecustodyplacea 5nancialburdenonthepublicpurse' +uchcostsaredifculttoestimateand

depend

on

the

circumstances

o#

each

death-

but

e%en

the

most

straight#orward

case is

li&ely

to

cost

tens

o#

thousands

o#

pounds' For

instance-

in

one

uncontro%ersial

199$case-whereadetaineedied#romperitonitis-thepolice admii strat i o co sts aloewere estimatedtobeQ0-22Ei#PC*-CP+andtheCoroner/scostshadbeen included-thetotalcostswouldha%ebeenmuchhigher' =heredeathsare contro%ersialandin%ol%ecourtcases-thepubliccostscouldbe%eryhighindeed' ?%enaconser%ati%e5gureo#-#orinstance-ana%erageQ2-222percaseintoday/s termswouldsuggestthatthecosttothepublico#dealingwiththe$00cases consideredinthisreportwouldha%ebeenQ8'million'

"he1ac%'rou&d)o)herepor)

+ince1992-ana%erageo#NGpeopleperyearha%ebeenrecordedasha%ingdied whilstinpolicecustodyin?nglandand=ales'O#these-asmallnumbero#cases ha%erecei%edparticularattentionbecauseo#claimsthatofcerswere-tosome e,tent-responsible#orwhathappened' Thisresearchwasinitiated-in+pring1990- asaresulto#continuingconcernaboutthenumberandcircumstanceso#deathsin policecustodyontheparto#thePoliceComplaints*uthority!PC*"-the *ssociationo#Chie#PoliceOfcers!*CPO"-the*ssociationo#Police+urgeons !*P+"andtheHomeOfce' Theaudience#orthereport-howe%er-isnaturally#ar widerthantheseinterestedpartiesandthewor&there#oresee&stoaddressmanyo# the&eyissuessur roundingdeathsinpolicecustody'

Thereporte,aminesthecircumstancessurroundingmosto#thedeathsinpolice custodythatha%eoccur redsince1992' 6tsprimaryob7ecti%eistohighlight

common#actorsinthesedeathsandanylessonsthatcanbedrawn#romthese 5ndingsinthehopethat#uturedeathsmightbea%oided' Thereportdoesnotset outtoplacetheblameonanyindi%idual-nortoconcentrateonanyparticular caseso#thosewee,amined' 6nstead-itaimstoe,aminedeathsasawholeandto learnlessons#romthe 1ee ralratherthanindi%idualcircumstances'

9Hom eOfice *o so l id at e d *irc ul aro *rime ad

:i d red 4a tt e rs;5e, ruary

%&&=).

"herepor)5s(e)hodolo'

RecordscollectedbytheHomeOfcewereusedasthestartingpoint#or identi#yingdeathsinpolicecustody#orthisstudy' From1984$-police#orcesha%ebeenre(uiredtoreportcertaindeathstotheHomeOfce-andthedatathey pro%idearepublishedannuallyinHomeOfce+tatisticalAulletins' Ao,1setsout


18/109

thecircumstancesunderwhich#orcesshouldreportsuchadeath'6ntotal-.80 dea)hs werereportedunderthisprocessbetween1anuary1992and3ecember1994 inclusi%e'

Bo+1: "he$ppe&d i+72de0i&i)io&o0dea)hsi&policecus)odoro)herwise wi)h)hepo lice

2a)e'or-$> wherethedeceasedwasarrestedanddied>

whilstbeingdetainedinapolicestationorelsewhere!e,cepti#theywereatcourt a#terbeingcharged"

whilstbeingheldintemporarypoliceaccommodation whilstinhospitalorinapolice%ehicle'

2a)e'or-B>wherethedeceasedwasotherwiseinthehandso#thepoliceordeath resulted#romtheactionso#apoliceofcerinthepurportede,ecutiono#hisduty' 6ncludingcaseswherethedeceased>

wasasuspectbeinginter%iewedbutnotdetained wasacti%elyattemptingtoe%adearrest

wasstoppedandsearchedor(uestionedbythepolice

wasinapolice%ehiclewhilstinpolicedetention

wasincustodyha%ingbeenarrestedunderthe6mmigration*ct1901-the*sylumand 6mmigration*ppeals*ct199F-ordetained#ortheirownsa#etyunderthe@ental Health*ct198ForChildren*ct1989

wasacon%ictedorremand prisoner heldinpolicecellsonbehal#o#thePrison+er%ice

wasin%ol%edinasiegesituationorambush'

Our&ey concern was to ensure that cases were e,amined #romwhich thepolice could learnlessons'One,amining thesample-howe%er-werealised-ashad an earl ierstudy intodeaths inthe@etropolitanPolice+er%iceF-that therewere a number o# deathswhere thepolice presencehad been tangential' 6nmany cases theindi%idualswhodiedwerenot e%entechnically.arrested/letalonephysica lly inpolice cus todyordetention'+uche,amples includedcaseswhere aman

wal&ed intoa policestationandcollapsedanddied atthe#rontdes&- andanother wherethepolice had #oundapersoncollapsedinthestreet whodiedshortlya#ter theo##icersarri%ed'=econse(uent lye,cluded cases where thedeceased hadnot been restrainedor wasnottechnicallyarrestedor detained at thetimeo#death' =ealsoe,cluded cases in%ol%ing police %ehicle pursuits and those in%ol%ing policeshooting incidents!#or instanceduringsieges" becausethese

o#tenin%ol%ed uni(uecharacteristicsmoreappropriate toa separate study'*ssuch-wee,cluded

; ?;essons#romTragedies> 3eathsin custody in the

@etropo l itanPolice 3istrict

19849N" @ >irstRep o rt,y th eDe athsi *usto dy$o rki 1

Gro upo +th e*o mm ui tyAPo l i ce

*o su l tat i- eG roup+o r

Lam , e th

(%&&=).


19/109

88 cases'The main e,planations #ore,cludingcases were thatthedeceased>

hadnotbeenrestrainedandwasnotunderarrest-butwaspro%idingassistance- helpingwithen(uiries-ormerelyatapolicestationatthetime!.cases"L

wasbeingpursuedbypolice!eitheron#ootorby%ehicle"buthadnotyetbeen arrestedorrestrained-andpolicewerenotpresentwhenthedeathor

#atal in7uriesoccurred!27cases"L

hadearlierbeenreleased#romcustody!12cases"L

wasnotar restedorrestrained-but#ounddeadordying#romtheirownearlier actionsorthoseo#anotherpersonandthepolicewerenotpresentatthetimeo# theactions!8cases"Lor

haddiedduringasiegeor#rompoliceuseo#5rearms!/cases"'

Fromtheremaining 2;2cases -wee,cluded 1.cases becausetherewassolittle in#ormationa%ailablethatwecouldnotestablishwhetherornot

theymetour criteria#orinclusion' =ealsoe,cludeda#urther2cases #rom1992becausethe deceasedhadbeenarrestedin1989Eoutsidethedatacaptureperiod' 6ntotal- there#ore-weidenti5ed2//dea)hs #orwhichwecollecteddata'

=eagreedwithHomeOfcePolicyDnits-thePC*-*P+and*CPOwhat in#ormationweshouldgathertoaddresstheir%ariousinterests-andtobestidenti#y lessons#romthese$00deaths' Themaindatasourcewasthe5leo#thein(uiry conductedbythePC*' Howe%er-note%erydeathhadbeenre#erredtothePC* and-insuchcases-wereliedon#orcerecords'6nthosecaseswheretheserecords werenolongera%ailable-orlac&eddetail-wesoughtdata#romCoroners/5les'

B'hrou1 h outthi srepo rt72e use th ete rm sCdoctorDad

CF@?D i t e rc h a1e a,ly(ul e ss2e make clear th at2e mea

ah ospi tal d o c t o r )ad th ete rmmCedicDt o re +e rto

p aramedic s7em e r1ecy medic alte ch i c ia sad am, ul ac e

te ch i c ia s.

561 ram!.ad /oh soG. (%&&E)? +el#Harmand

+uicide by3etainedPersons>*+tudy "7 Po l i c e

Re se arc h!2ard#c h em e Pape r7Lo d o :Home Ofic e.

"hepurpose o0)herepor)a&di)sli(i)a)io&s

*lthoughin#ormationrelatingtoi d i - i d ualcasesisa%ailable-littleinthewayo# collateddata ondeathsinpolicecustodyhasbeenpublished'*nnualHomeOfce+tatisticalAulletinsha%eincludedin#ormationonthetotalnumbero#deaths-the ageandgendero#thedeceased-theirplaceo#deathandcauseo#death'Howe%er- moredetailedin#ormationsuchasthedetainee/sethnicity-theirreason#orarrest- howtheywererestrained-andtheactionso#custodysta8anddoctorsG-ha%enot beencollectedinasystematicway' Thisstudy/sob7ecti%es-there#ore-wereto gatherande,aminecollatedin#ormationondeathsinpolicecustodyin?ngland and=aleswhichwasnota%ailableelsewhere-andtoidenti#yanyrecurrentcommon#actorswhichmightin#ormchangesinpolicepracticesrelatingtocustody matters' Toma&ethetas&easier-wewereabletobuildonande,tenda

database de%eloped

by

6ngram

and1ohnson

#or

an

earlier

report

on

deaths

in

police

custody

N

'


20/109

Ourintention-also-wastousethedatawecollectedtoin#ormthedebateabout deathsinpolicecustody' =edid o te,pecttobeabletoanswerallthe(uestions withthein#ormationwegathered#romthe5les' Ouraimwastoestablishwhat couldbelearnt#romtherecordsEwhethertheypro%idedanyuse#ulinsightsor raisedotherissuesthatmightbeconsideredinthe#uture'

The researchaddressed a wide rangeo# issues drawing #roma considerable %olume o#data#romala rgenumbe ro#cases' Readersshould bearinmind- howe%er-the #o llowingca%ea tsabout the natureo#theda taco llectedandhow we interp retedthem>

=ecouldnote,aminecaseswheredetaineeswere sa-e dbytheactionso# ofcers-custodyormedicalsta8' Therewerealmostcertainlymanymoresuch casesthandeathso%ertheperiode,aminedandtheywouldprobablyyield %aluablegoodpracticelessons'*%erydi8erentstudywouldha%ebeenre(uired- howe%er-toidenti#yandlearn#romthesecases'Furthermore-inmostinstances- wecouldnotcomparethecircumstanceso#thepeoplewhod i e dincustodywith thoseo# al lthepeoplewhohadpassedthroughcustody-becausedata#orthe custodialpopulation4wereuna%ailable'

Aecause o#

di##erent

standards in reporting

procedures-

there

were

numerous gaps

in

the

data originally recorded

and

collected- resu lting

in

incomplete

data #or some%ariab les0' 6Os/reportson dea ths-#orinstance-%ariedin their detail and length #romon lyone side o# *G paper-to %olumes o#in#ormat ion' Furthermore-where theywe rea%ailable- therecordswe usedhad notbeen writtenwith #uture researchneeds in mind-but aspar to#thein%estigati%e process#ollowingeach death'*sa result-therecordso#ten did notpro%ide all thedata wewanted #or each case' +ome o# ouranalysesmaynot-there#ore- ha%e been based onthe .#ull picture/'

The dataco ll ec tionwas pr imari ly#romdocumentarysourcesE #romthe #i les made a%ai lab letous' =etoo& great caretoensurethatthe datawec ollectedco%eredissueso#int eresttothepol ice-themedica lpr o#essionand agencies in%ol%edinin%est igat ingdeaths-buttheresearchitse l#

d idnot inc ludeint er%iewswith-orsur%eyso#-these orother inte restedparties' 6t wasbeyond thescope o#thisstudyto reconsiderthecircumstanceso#each death-and any (uali tat i%eda tawere drawn#romthesummarie sandnotes at tachedtothe case #iles'

Therecordsweusedtoldtheo fic i al accounto#whathappenedEinsomecases- otherpartiesmaydisputethataccount' 6twasnotthepurposeo#thisstudyto

=>o ri stac e7thei rre aso+o r ,ei1 arre ste d72heth e r

re strait 2asused i th ei rarest72heth e r th eysufe red+roma

medic al coditio o rh adco sumed alcohol o rd ru1 s7et c .

E6 t2o case s7 alm os t al l th e -ari a, l es +o r th e

i d i -i dual 2e rem i ssi 1.'he +i rsto +

th e sedied +ro mi h al i 1hi s o2 -omi ta+ter

,e i 1leC#t undisturbed'''snoringD.

'h

e secod died o +

nCatural causesD

a+te r

h

a-i1,e e

, ro u1hti i adC run&en stateD.'hese t2o

c ases

appe arthrou1 h o u tm uc ho +th emo red etai l e da a lysi sas

Cm i ssi 1c ase sD.


21/109

re9e%aluatetherecordsLrather-wesimplye,tractedthedataneeded#orour analyses' Howe%er-itisimportanttorecognisethatinsomecases-othersmightchallengetheofcialrecordandthat-wor&ing#romtheir%ersiono#e%ents-someo#theconclusionsinthisstudymightbedi8erent'

Theresearchwasnecessarilyretrospecti%e' *nalternati%eapproachwouldha%e beentocollecte,tensi%eandup9to9datein#ormationbygatheringdata#romselected#orcesondeathsastheyoccurredo%eranagreedperiod' Thishowe%er- wouldha%ein%ol%edwaiting#orin(uiriesintoindi%idualdeathstobecompleted !whichmightha%eta&enmanyyears"'

Thedeathswee,aminedwere#ewanddispersedEbothgeographicallyando%er timeEo#tenma&ingitdifculttoidenti#ystatisticallysigni5cant5ndings

!althoughthisdidnot-o#course-pre%entus#romdrawingoutpossiblelessons whichseemedtoemerge#romthecases"'

=ecoulddraw#ewconclusionsaboutthe(ualityo#careandthecustody practices1ee ral lye,hibitedbypoliceofcersinthe%astma7orityo#cases' +ome

o#

the$00

cases

re)ected

situations

where

there

may

ha%e

been

errors

on

theparto#thepoliceormedicalpro#essionEbutwehadnowayo#&nowingwhether thesecasesre)ectedunderlyingproblemsinhowtheser%icedealswithdetainees-orwhethertheywereoccasionallapsesinasystemthatgenerally wor&swell'

6#there2e reoccasionallapses-thisstudycouldnotestablishho2o +te theselapses occurred'Theremaybemanyothere,amples o#similarpoorpracticewhere the detaineehappened nottodieEbutoursampletoldusnothingaboutthese'

*sa conse(uence- int ryingto drawlessons#romthe$00 deaths-careshou ldbe ta&enin gene ra lis ing#romthese e,cep t iona lcases>what app ears

tobe a use#ul l

esson#romone case may notbe approp riateorrea

listici# app

liedac rossthe board'

6tisimportanttoemphasiseoneotherpoint>thatthisreportisnotabout apportioning.blame/Eeithercollecti%ely-orinparticularcases' 3espitethebest e8ortso#thosenearby-peopleinallpartso#societyo#tendodiesuddenlyand une,pectedly-wherelittlecouldha%ebeendonetoa%oidthedeath' O#ten-the recordswee,aminedsuggestedthatofcersordoctorsin%ol%ed#oundthemsel%es ha%ingtothin&(uic&lyindifcultcircumstances-anditiseasytoidenti#yerrorsinh i d si1 h'te%ertheless-therewereoccasionswhereitappearedthathadofcers-


22/109

doctorsormedicsactedearlierordi8erentlytheindi%idualwhodiedmightha%e sur%i%ed'

Thissaid-inthecaseswedescribewherethereappeartoha%ebeen#ailings-itmay ha%ebeenthatofcershadrecei%edpoororinade(uateguidance' =edidnotsee& toe,aminewhetherofcershad#ailedto#ollowtheire,isting#orceguidelines-or whethertheseguidelineswereinade(uate-inappropriate-incorrector#ailedtoco%erthecircumstanceso#thedeath' Thiswouldha%ebeene,tremelydifcultto researchbecauseitwouldha%ere(uiredhistoricalin#ormationontheguidancetoallofcersineach#orceandhowithadchangedo%erthese%enyears!sometimes inreactiontoadeathorotherincident"' 6twouldalsoha%ere(uiredustoma&ea sub7ecti%eassessmento#thee,tenttowhiche%erysingleofcerin%ol%edineach separatecasewasawareo#theguidance-whethertheyhad#olloweditbytheir actionsorinaction-orwhethertheguidancewasinade(uate' Fromoure,perience itwasclearthatthedatawouldnotha%ebeena%ailabletocompletesuchatas& ade(uately' Furthermore-our#ocuswasonhighlightinggenerallessonsthatmight helptoreducetheli&elihoodo#deathsoccurringinthe+uture-notonapportioning blametoofcersorproceduresinindi%idualcases#romthepast'Howe%er-sincewedidnote,aminetheseissuesinthisstudy-readersshouldbeawarethat-insome cases-apparent#ailingsmayha%ebeenthe.#ault/o#thesystematthe

time-

rather than

the

ofcers

in%ol%ed'

Theca%eatsdescribedabo%e-althoughimportant-shouldnotdetract#romthe principalmessageo#thisreport>thatsome#uturedeathsincustodymightbea%oidedpro%idedthoseresponsible#orthecareo#detainedpersonscontinueto learn#rome,perienceinpastcases'

"hes)ruc)ureo0)herepor )

+ection$pro5lestheindi%idualswhodiedinpolicecustodyandcategorisesthe maincauseso#death' +ectionsFandGconsidercaseswherethedeceased/sown actionsweretheprimarycontributorycauseo#theirdeath-whilst+ectionN e,aminescaseswherethedeceasedapparentlydied#romamedical

condition' +ection4considerstheissueo#policerestraintanditsapplicationtoindi%iduals wholaterdiedincustody-whilst+ection0e,amineswhetherthereisany relationshipbetweenethnicityandthecircumstanceso#deathsinpolicecustody' +ection8e,aminestheactionso#themedicalpro#ession' Finally-whilst+ectionsFto8areprimarilydescripti%einnature-+ection9drawstogetherallthelessons learnedtopro%iderecommendations#orthepoliceandthemedicalser%ices'


23/109

C*T?OR6+6TH?3?*TH+

2 2a)e'orisi&')hedea)hs

Wh odiedwherea&dwhe&9

O#allthedetainees inthe$00caseswee,amined-o%erwhelmingma7oritieswere classi#iedas>whiteLmaleLbetweentheageso#$2andN2LunemployedLnotmarriedL ha%ing asettledaddress andarrestedintheirlocal#orcearea!Table1"' Their characteristicsweremoreli&elytoha%ere#lectedthecustodialthanthegeneral population-although thedataa%ailableinthisstudydid notallowthis tobechec&ed'

"a1le1:


24/109

C*T?OR6+6TH?3?*TH+

"a1le2: Reaso&s0orar res) 1

Reaso&0orar res) Nu(1erarres)edPerce&)a'e o0

sa(ple

3run&andincapableJdrun&anddisorderlyJdrin&dri%ing 119 GN:

The#t!shopli#ting-etc'" F2 11:=arrantJplaceo#sa#etyJ@entalHealth*ctJprisoner $ $N 9:

Aurglaryandrobbery $$ 8:

3isorderJbreacho#thepeace 10 4:

*ssaultJAHJthreatsJunlaw#ul imprisonment 1G N:

CriminaldamageJarson 1$ N:

3rugs9related 1$ N:

RapeJindecente,posure 9 F:

@urderJmanslaughter G $:

"O"$3 24 100?

ote> 1 3ataonreasons#orarrestweremissinginthirteencases'$ Prisonertemporarilyheldinpolicecellsonbehal#o#theprisonser%ice'

a%eragelengtho#timespentbyadetaineeinpolicecustodywas4hoursandG2 minutesL#orlessseriouso8ences-thedurationa%eragedonlyFhoursandNF minutes8' 6twasnotsurprising-there#ore-thatthemedianlengtho#timebetween indi%idualsarri%inganddyinginthepolicestationwasonlyGhoursandN4minutes' i%enthisrelati%elyshortperiodo#timebetweenarrest anddeath-itwas alsonotsurprisingthatG2:o#deathsinpolicestationsoccurredbetween11pmandNam-sinceG1:o#allthosewhodiedinpolicestationshadbeenarrested between4pmandmidnight'

2a)e'orisi&')hedea)hs:causal 0ac)ors

The

deaths

could

be

categorised

by

their> medicalcause -suchasheartattac&Land

combination o# potentiallyrelated0ac)ors-such asthe person/s circumstances and actions-in7uries #roman accident-adrugso%erdose orconsumptiono# e,cess alcohol'

6nitially-westudiedrecordso#pathologists/reportstoidenti#ythecausesand #actors-but#oundtheyweredifculttocategorise' Forinstance-pathologistso#tenrecordedmorethanonemedicalcauseLonedetainee-#ore,ample-wasrecordedas ha%ingdied#rom, rai de ath


25/109

&6c l udi1rel ate d-e rd i c t ssuc h asCtoo&ownli#eDad

C&illed himJhersel#D.

andcausesweresohardtoseparate-theytendedtobeusedinterchangeablyE#or instance-onedetaineedied#romo- e r2h e l m i 1ad rapid p ro1 re ssi- ep e umo i adue to !6D# ad cotiued misuse o +d ruI1's=ethere#ore#ounditimpracticaltoseparate#actorsandmedicalcausesandthisreportdoesnotdistinguishbetween thetwo'Forinstance-weclassi5edh a1 iI1!strictlya#actor"asacauseo#death wheretheactual medicalcausemightha%ebeenrecordedas-a1 ali hi, i t i oI' ;i&ewise-d ru1a, useI!again-a#actor"hasbeenre#erredtoasacauseo#death- whenin#actthemedicalcausemightbepulmoaryoedema iduced ,yd ruI1' s=e hopethisapproachma&esthereportmoreaccessibletothelayreaderLwealso #ounditmadeiteasiertoidenti#ytheemerginglessons'

*notherdifcultywasthatCoroners/%erdictssometimesappearedto.con)ict/ withpathologists/reports'=hereaspathologistssee&toidenti#yonlymedical causeso#death-Coronerssee&toe,plainthecircumstancessurroundingdeathsby ta&ingall#actorsandcauses-intoaccountEincludingmedicalcauses' ?,ampleswherecausesand%erdictsseemedtodi8erincludedthe#ollowing>

*lthoughthemostcommon%erdictwasac c i d e t alde atIh-representing$N:o# cases-therelatedmedicalcausesinthesecasesranged#rombronchialpneumonia toheartattac&-headin7ury-hanging-li%er#ailure-posturalasphy,iaandacute alcoholpoisoning'

For thene,tmost #re(uent%erdict-atural

c ause sI!$1:o#cases"-pathologists reportedasimilarmi,ed rangeo#causesnotalways immediatelyapparent#rom the%erdict'

Coronersalsoappearedreluctanttorecord%erdictso#sui c i d eD&-perhapsbecauseit wasnotclearwhetherthedeceasedintendedtodieor7ustharmthemsel%es' 6ngramand1ohnson!1990" N notedthat-whereadetaineehaddiedasaresulto# deliberatesel#harm!3+H"-Coronerso#tenreturned%erdictssuchasCmi sad-etureD7Cac c i d e t D7orCo p eD'Conse(uently-whilesomemightseesuch deathsassuicides-theyarenotincludedinthesuicidestatistics' Thisalso complicatedourattemptstocategorisethedeaths'

i%enthesecomplications-wedecidedtocategorisethedeathsbyre#erringtothe 5lenotes-andinterpretingwhetherthecausal0ac)ors o#eachdeathrelatedprimarilyto>

thedeceased/sownactionsL anunderlyingmedicalconditionLor theactionso#anotherindi%idual'

Thesethreecategoriesarereportedin Tab leF- bro&endown into#i#teen subcategories'


26/109

C*T?OR6+6TH?3?*TH+


27/109

C*T?OR6+6TH?3?*TH+

i%enthecomple,anduni(uearrayo#circumstancesassociatedwitheachdeath- thewaythesecategorieswereconstructedwasbothdifcultandsomewhatarti5cial' 6twasoccasionallyhard-#ore,ample-toestablishwhetheracaseo# poisoningshouldbelistedassu, stac ea, useD7D#HIor l i - e rp ro , l emI'Forsuch cases-were#erredtothe5lenotestoestablishtheapparentitetioso# the deceasedandthe&ey#actorthatledtothedeath'

*lthoughwecouldha%ecategorisedthedeathsbyin(uestoutcome-weconcluded that%erdictssuchas Cmisad-etureD-Cac c i d e t alde ath DandCo p eDdidnotuse#ully con%ey-#orourpurposes-therealissuesunderlyingthecases' Thisdoesnotmean- howe%er-thatthecategoriesweusedborenorelationtotheCoroners/%erdicts>#or instance-Csui c i d eD%erdicts#ellwithinour3+Hcategories-andalmostallthe naturalcausesI%erdicts#ellwithinourcategory#ordeaths#rommedicalcauses' Ouruseo#causal#actorshadtheaddedad%antageo#identi#yingthecircumstances moreclearlysothatwecoulddrawpossiblelessons' Forinstance-wecouldgroup manyo#thenaturalcausesIcasesintocategoriessuchasheartproblemsorhead in7uriesEallowingustoconsiderthe&eypointsrelatingtoeach' Hadwereliedon Coroners/%erdictsaloneitwouldha%ebeenmuchhardertoidenti#ythema7or issuesandlessons'There#ore-whileourapproachnecessarilyintroducedadegreeo# sub7ecti%ity-italsopro%idedause#ul#ramewororconsideringthedeathsand producing theresto#thisreport'


28/109

TH?3?C?*+?3/+O=*CT6O+E3?;6A?R*T?+?;FH*R@

."hedeceased5sow&ac)io&s6deli1era)e sel0har (

Ide&)i0-i&')hedea)hs1S#

=ecategorisedasdeliberatesel#harm!3+H"caseswheretheindi%iduald e l i , e rate ly harmedthemsel%esanddiedasaresulto#theiractionsE2heth e rth eyh adapp aretly iteded to die o r'o6tnmanyo#thecasesweincluded-there#ore-thedetaineemay ha%ediedunintentionallya#terdeliberatelyharmingthemsel%esasa.cry#orhelp/ora.manipulati%egesture/'Forthisreason-thenumbero#3+Hcasesweidenti5ed e,ceededthenumbero#suicidesrecorded'

6ngramand1ohnson!1990"identi5edN$casesbetween1992and199Gwherethe deceasedharmedthemsel%es a+te rbeingta&enintocustody!i&-cus)od:S# "-all o#whichareincludedinthisstudy' =eaddedcasesoccurringa#ter199Gand identi5edallthosedeathso%erthese%enyearswherethedeceasedhadapparently intentionallyharmedthemsel%es ,e +o retheywereinpolicecustody!pre-cus)od :S#"' Thelattercaseswerenotalwayseasytoidenti#ywithoutcare#ul considerationo#thecircumstances' Forinstance-wetoo&thee,istenceo#asuicidenote-oractionswhichthedeceasedwouldclearlyha%e&nownwouldcause personalin7ury!#orinstanceamassi%eo%erdose"-ase%idenceo#deliberateharm' =here-howe%er-thedetaineedidnotappeartoha%ed e l i , e rate lyharmed themsel%es!#orinstanceanaccidental#atalo%erdose"weclassi5edthedeathassubstanceabuse'Together-pre9andin9custody3+Hrepresented9Fdeaths-more thanone9thirdo#allcasesEma&ing3+Hthebiggestsinglecauseo#

deathsin policecustody' Theycanbebro&endowninto>

pre-cus)od:S# >si,teeno#these%enteencasesin%ol%eddrugso%erdoses12- perhapsunsurprisinglyaso%erdoseswerethemostob%iouswayo#lightinga hidden#useI-thee8ectso#whichonlybecameapparenta+te rtheindi%idualwas incustodyLand

i&-cus)od:S# >o#the04cases-0Fin%ol%edhangings11'

Howe%er-thesedeathsneedtobeputintoconte,t>

i%enthedeterminationo#someindi%idualsto&illthemsel%es-thedeathswere notalwaysreadilypre%entable' +uccess#ulsuicide attemp tswere rareinpolice custody'6ngramand 1ohnson !1990" estimatedthat-during si, months in1994- therecould ha%e

been at least11F1 in9cus tody3+H attemp tsin police cus todyin?ngland and=ales- suggest ingthat near ly14-222 3+H attempts may ha%ebeen made bydetainees inpolicecustodybetween1992 and19901$' The 04 cases identi# iedinthis studythere#oresuggestthat #ewerthan1in $22 in9custody3+H attempts resultedindeath'

%0

'h e

se - e t e e t h

case i-ol-ed a +em al e

2ated +o r

a

susp e c t e d o fece2h o7h a- i 1,ee sp o t t e d ,ya o fic e r7

+atal lysta,,ed

h e rse l+2hi l strui1 a2ay(i e fec td e l i , erat elyh armi1h e rse l+

be#ore ,ei1 takeito c usto dy).

%

%O+the ot h erthreec ase s7o e 2asdue to

su++oc ati o as a

re sulto +the detai e estu++i 1hi s m outh2 i thtoi l etp ap er

ad a

so c kG

oe i di - i d ual

sta, ,e dhim se l+as th ep o l ic eatte mp te dto

d i sarmh im Gad the thirdsh ot

h im se l+i the h e adas th ep ol ic e

trie dtostoph im .

%9'hi sco uld,e a ud eAr e sti m ate 7sice 61 ram

ad

/oh so "sc alc ul at i o se 3c l uded th e4etro p o l i t aPo l i c e

#e r- i c e.


29/109

TH?3?C?*+?3/+O=*CT6O+E3?;6A?R*T?+?;FH*R@

6tmustbestressedagainthatthepresentstudytellsusnothingo#thecases wherethedetaineessur%i%ed'i%enthatanestimated#ewerthan1:o#3+H attemptsresultedindeath-itwouldseemli&elythatinatleastsomeo#the3+H caseswheredetaineesgenuinelyattemptedsuicide-prompt-appropriateactionby thepoliceprobablysa%edtheirli%es'

e%ertheless-therearestilllessonstobelearned#romthe3+Hdeathsthatdid occur-andthesearee,ploredbelow'

%;$euse th ete rmPOL%i th i s repo rtto re +e rto ay+o rm

2h ic h se r-e dth epurpose de sc ri , e dhee r (+o ri stac e7th e

4etro p o l i t a Po l i c e#e r- i c eused >o rm=%). POL%sare to

,e rep l ace d

,y Pri so e r

Esco rt

Rec o rds

(PER s)7 2hich 2i l l

,e comple tfeod reveryprisoner,ypolice custo dystaf7

mem, e rso +H4Pri so#e r- i c e ad p ri so e re sco rt

a1 e c i e s.

%B$euse th ete rm sCcusto dy o fic e rDad Cc usto dystafD

i t e rc h a1 ea,lyi thi srep o rt. $edid ot 1 ath e rdatato

di st i 1 ui sh,et2ee 2heth e rth e custody stafi e achcase 2e r

re1 ul arofic e rso rc i - i l i as.

%56 1 ram! .ad /o h soG. (%&&)?3e liberate

+el#Harm and+uicideby3etained Persons E*n

6n#ormat ion Aoo&let#orPolice Custody +ta##"7Po l i ce

Re search

Gorup.

War&i&'si'&sa))hepoi&)o0de)e&)io&

Possiblewar&i&'si'&s o#atendencyto3+Hincluded>

Csui c i d eDmar&ersonthePoliceationalComputer!PC"Land

in#ormationon?,ceptionalRis&I#orms!PO;1s1F"'

PO;1sarecreatedbypoliceofcersandmemberso#H@Prison+er%iceorprisoner escortser%ices-whentheyconcludethatadetaineemaybeCat

e 3 c e p t i o al

ri skDor maypresentaris&tothoseholdingortransportingthem' Ofcerstic&bo,esonthe#ormtoidenti#ytheris&!s"#romamongstse%enpossiblecategories!plusone Cot h e rDcategory"-thema7orityo#whichre#ertothedangerthedetaineepresentsto others-ratherthantoris&stothedetainee/swell9being'The#orm.tra%els/withthe detaineewhilsttheyareincustodytoalerttheofcersresponsible#orthedetainee totheris&'6nsome#orces-whenadetaineeisbroughtintoacomputerisedcustody suite-aPO;1iscreatedautomaticallyi#acustodyofcer1Gma&esaPCchec& whichre%ealsthatthepersonhasmar&ersindicatingtheyare.atris&/orposearis&' 6nother#orces-thecustodyofcerhasphysicallytocreateaPO;1i#aPCchec& re%ealsmar&ers' Ofcersshouldalsoha%eraisedaPO;1i#adetainee-whilstin theircustody-beha%edinawaythatsuggestedtheymightharmthemsel%esor others'

6ntermso#3+Hwar&i&'si'&s atthepointo#detention-there#ore-thepolicemay beabletodetect#romaPO;1-handedo%erbyanotherstationortheprison ser%ice-thataprisonermayharmthemsel%es'Oncethedetaineeisincustody- custodysta8startinganewshi#tshouldbeabletotell#romaPO;1whethera detaineehadpre%iouslyshown3+Hwarningsigns' PCchec&smayalsoalert custodysta8toCsui c i d eDmar&ers'

6naddition-6ngramand1ohnson 1Nalsoemphasisedtheneed#orcustodyofcersto watch#orparticular 1eha,ioural si'&als whichsuggestedthedetaineemightha%e alreadyharmedthemsel%esorcouldgoontodoso' +uchsignalsincluded>


30/109

directe,pressionso#intent!e'g'6"m1oi1 to sl ashuIp"L

e,pressionso##ailure-guiltorhopelessness!e'g''h e re"so poit i 1oi1 oI"L

signso#past3+H!e'g'scars#rompre%iousattempts"Land

ac(uisitiono#implements!e'g'secretingbitso#plasticcutleryandligatures"'

=eattemptedtoident i#ythee,ten ttowhich apparentwarningsigns and beha%iouralsignals e,isted thatmight ha%e alertedo#5cerstother is&o# 3+H'6mportant ly-in upto82:o#3+Hcases-there wereoapparentsignsor signa ls !TableG"' =henthese detainees were ta&eninto custody-o##icerswou ld apparentlyha%ehad no indication theywereat greater r is&o# 3+H thanany otherdetainee'

"a1le4: S#war&i&'si'&sa&d1eha,iouralsi'&alswhe& )hede)ai&eeswere )a%e&i&)ocus)od

$lldea)hs1eli1era)eSel 0#ar(

Pre9custody3+H!n10"

6n9custody3+H!n04"

*ll3+Hcases!n9"

oapparentwarningorPO;1 12 !N9:" NG !01:" 4G !49:"

PO;1raised#oranun&nownreasonand apparentlynootherwarning 1 12 11

*pparent3+Hwarningsignsorsignals thatmightha%ebeennoted 4 !FN:" 1$ !14:" 18 !19:"

o#which''''''

PC.suicide/mar&er1 E 1 1

Aeha%iouralsignals F F 4

PO;1ad

PC.suicide/mar&er1 E F F

PO;1andbeha%iouralsignals $ G 4

PC.suicide/mar&erandbeha%iouralsignals1 1 1 $

ote>1 oneo#thedetaineeswithCsui c i dalDmar&ersonthePCwereanonymouson detention'

6nthecaseswee,amined-wewereabletoidenti#ydetainees#orwhomaPO;1had beencreatedatsomepoint-butnotwhenithadbeencreated-northeris&about whichthePO;1hadwarned' Dltimately-there#ore-theonlyclearwarningsignsor signalsweidenti5edthatcouldha%ebeena%ailabletocustodyofcerswouldha%e beenPCmar&ersandthedetainees/beha%iour' e%ertheless-o#the$1detainees #orwhomPO;1shadbeencreated-$2died#rom3+H' O#these$2people-nine displayedotherwarningsignsorbeha%iouralsignalsinadditiontothoserecorded


31/109

onthePO;1' Furthermore-someo#theremainingele%endetainees#orwhomthe olywarning signwasaPO;1-mayha%ehadthe#ormcreatedbecausetheyhad displayedsuicidaltendenciesatsomepoint'

6nthreecases-therewasaCsui c i d alDmar&eronthePC!and-intwoo#these cases-beha%iouralwarningsignals"butcustodyofcersdidnotraiseaPO;1Ein onecase-itwasrecordedthatthiswasbecausetheyhadnotchec&edthePC' 6n

a#urthersi,cases-therecordsappearedtoindicatethatthedetaineewasdisplaying possible3+Hbeha%iouralwarningsignals-butnoPO;1wasraised'

6tdoes-o#course-ha%etobenotedthat19:o#the3+Hdeathsdi dapparently presentwarningsignsordisplaybeha%iouralsignalsduringcustody-andthatas manyasF1:mayha%edone!i#allthePO;1shadrelatedtosuicideris&s"' 3oes thismeanthepolicewerenegligentinmissingse%eralpossible3+HdeathsM 6n answeringthis-thewarningsignsandsignalsmustbe%iewedinconte,t>

%='h ete rm>o re sic4e d i c alE3amie r

(>4E)

re +e rs

t o

doctors 2h oare police sur1eos.

'h eyare usual lyGPsp ro - i d i 1

a o Ac al lse r- i c eto a+o rce+o ra

+eead retai e.r

6none9thirdo#allthein9custody3+Hcases-aForensic@edical?,aminer !F@?"14hade,aminedthedetaineeanddeclaredthem.5ttobedetained/!sometimesmorethanonce"' O#these$Fdetaineese,aminedanddeclared.5t/- recordssuggestedthateightmayha%epresentedwarningsignsorsignals' 6#the warningsignalshadnotcausedundueconcern#oranF@?-therewasprobably littlereason#orcustodysta8toremainconcernedaboutthedetainee/scondition'

6nse%eno#thesi,teencaseso#pre9custodyo%erdose-thepolicedi drespond promptlytothewarningsigns-callingadoctororanambulanceassoonasthe suspectarri%edincustody' 6ntwoo#thesese%encases-howe%er-anF@?had declaredthesuspectswere.5ttodetain/' Thisindicatesthatwarningsignsand signalscanbeambiguous'F@?sareusuallyPs-and#ewareli&elytoha%e recei%edthenecessarytrainingtobeabletoidenti#ysuicidaltendencies'Custodyofcers-howe%er-muststillrelyonF@?s#orapro#essionalopinionand arenoteasilyabletoo%erruletheirdiagnosisonceithasbeengi%en'ThissuggeststhatF@?sshouldbeade(uatelytrained#orthetas&andmustta&egreat carewhenpro%idingadiagnosis'

6noursampleo#$00deaths-o#thetwel%epeoplewithPCCsui c i d eDmar&ers- si,diedby3+H' ThisdemonstratesthatCsui c i d eDmar&ersshouldalwaysbe treatedseriouslybycustodyofcers-althoughtheyarenotanautomatic indicationthatadetaineewillattempt3+H'

=hatemerges#romthisistheunreliabilityo#thewarningsignsatpredicting3+Hdeaths>.#alsepositi%es/and.#alsenegati%es/abound' 6nmanycases-itwouldbe


32/109

unreasonabletoattachanyblametopoliceofcers#ormissingIthesewarning signs-sincetheyarealmostcertainlyrelati%elycommonplace-andthe%astma7ority o#detaineeswiththesesignswillprobably otgoonto3+H'Therewere-howe%er- anumbero#beha%iouralsignalsemerging#romourstudywhichappearedparticularlysalient' Thesearehighlightedbythee,amplesinAo,$-andillustrate theimportanceo#chec&ingdetainees#ortabletsore%idencethato%erdosesha%ebeenta&en-aswellasta&ingaccounto#signso#past3+Hattemptsando#repeated attemptsat3+Ha#terarrest'

Finally-althoughPCmar&ersandPO;1sarenotcompletelyreliablepredictorso# 3+H-theycanatleastalertcustodysta8toapotentialdanger-sotheycanpro%ide enhancedsuper%ision' 6nrelationtothis-twoadditionalpointsshouldbenoted'

Firstly-we#oundthat6OsdidnotconsistentlyrecordwhetherPCchec&shadbeenmadebycustodyofcers'Thissuggeststhatbetterrecord&eepingonthisissuemightbeappropriate' Then-inanycasewhereadetaineedied-thepolicewouldbeabletodemonstratemoreconsistentlythattheyhadunderta&entheappropriatechec&s'

+econdly-oneo#6ngramand1ohnson /s!1990"&eyconclusionswasthatPO;1 #ormswerenotbeingcompletedorusede8ecti%ely' 6nparticular-past3+H attemptsinpolicecustodywerenotalwaysenteredonthePC-andtherewasno mechanismtoensurethatprisonsuicideattemptswerenoti5edtothepolice' Furthermore-thecompletiono#aPO;1byacustodyofcerdidnotautomatically re(uirethemalsotoplaceamar&eronthePC' Thismeantthatindi%idualsin custodymayha%ebeen.atris&/withoutothercustodysta8ha%ingaccesstothis in#ormation' 6ndeed-inthepresentstudy-therewereNGin9custody3+Hdeaths wheretherewerenorecordedwarningsignsEinse%eno#thesecases-thedetainee hadpre%iouslyattempted3+Hbutthishadnotbeencommunicatedtothe arrestingorcustodyofcers' ?,amplesincluded>

apre%iousincidenthadbeenreportedinanother#orce-butnotenteredonPCL

onedetaineehadtriedtohanghimsel#inprisonbutpolicewereapparently unawareo#thisL

anotherhadattemptedsuicideinthesamepolicecellcomple,-buttherewasnoPCmar&erL

inonecase-a#teradetainee/spre%ious3+Hattempt-aPO;1wascompleted-but nomar&erputonthePCLand

onedetaineehadattemptedsuicideincustodyontwoseparateoccasions-but therewasnoPO;1raisedormar&erputonthePC'


33/109


34/109

Thesecommunication#ailuressupport6ngramand1ohnson/s!1990" recommendationsthatpolice-prisonsta8andprisonerescortsta8shouldalwayscompleteaPO;1a#terany3+HattemptLandthatPCandPhoeni,shouldalwaysbeupdated' Thisisnot7ustgoodpractice>in:irkh am- 'h e*hi e +*o sta, l e o +Gre ate r4ac h este rPo l i c e(%&&-)theCourto#*ppeal#oundthepolicewere negligentwhenthey#ailedtosupply-totheprisonauthorities-aPO;1re#erringtoadetainee/ssuicidaltendencies'

Theplannedreplacemento#thePO;1#ormwiththePrisoner?scortRecord!P?R" #orm-whichwillbecompleted#oralldetainees-isli&elytoimpro%etheris&assessmento#detainees-butitsimpactcouldbehamperedi#communicationsarenote8ecti%e'

"a%i&')hesuspec)si&)ocus)od

P*C?Codeso#Practice10allowcustodyofcerstowithholdadetainee/sc l o t h i 1 ad pe rso ale fe cItswheretheyconsiderth athe mayuse th emtocause h armt oh im se lI+' 6npractice-8$:o#detaineeshadhadi t e mswithheld-butwewereunable toestablishwhatproportiono#theseitemswereharmless!suchascash"-andwhat proportionhadbeenremo%edbecausethecustodyofcerconsideredtheymightbe used#or3+H' 6tseems-howe%er-thatinmosto#the3+Hcasesofcersdidnot remo%ee%erypossibleitemthatcouldbeused#or3+H-since40peoplewhohad itemswithheldmanagedtohangthemsel%esEusuallywiththeirownclothing !TableN"' Thesecasessupported6ngramand1ohnson /s!1990"recommendations thatcustodyofcerspayparticularattentiontoanyitemthatcouldbeusedasa ligature'ThecasesalsosupportedHomeOfceguidance18thatcellhatchessh ould ot ,e le +tope 2h eth ecell i soccupied ,yap ri sIo-bercausetheseareso#re(uently used#orattachingligatures'

%EP!*E*odeso +Prac t i c e7 *od e*B.9.

%Hom e

Ofice *irc ul ar Ho.

&9


35/109

Forcesha%emadee8ortsinrecentyearstotrytoguardagainstin9custody3+Hby detainees' Custodysta8ha%ebeenencouragedbyP*C?andinternal#orce guidelinestoma&etheirdetainees/healthandsa#etyaparamountconcern' Human ingenuity&nowsnobounds-howe%er-andaparticularlydeterminedpersoncanstill 5ndwaystoharmthemsel%es' .Tear9resistant/blan&etsandpapersuitsdonotp re - e t suicides!asoneo#thecaseswee,aminedillustrated"' 6nrecentyears-H@ Prison+er%icehasdonemuchwor&onthedesigno#.sa#ecells/' *lthoughdetaineesinpolicecellsclearlydi8er#romthoseinprisonintermso#their bac&ground-reason#ordetentionandlengtho#stay-theremaybesome

use#ul lessons#orcescouldlearn#romthesede%elopmentsinprisons'

%&P!*E*od eso +Prac t i c e7*od e*Hot e s+o rGuid ac e!.

2hec%i&'de)ai&eeswhils)i&cus)od

TheP*C?Codeso#Practice19statethatcustodyofcersshouldchec&ondetainees atleasthourlybut%isit.atris&/detaineesmo re+re. ue t lIy'

6#adetaineeissu8eringthee8ectso#apre9custodyo%erdose-theirli&elyrapid deteriorationinhealthismoreli&elytobeidenti5edintimei#chec&saremore#re(uent' Thisunderlinestheimportanceo#identi#yingpossiblewarningsignsas earlyaspossible' *lthoughtherecordsnotedthatrelati%ely#ewo#the3+Hdetaineeshade,hibited.atris&/warningsignals-there2ase%idencethatthosewho died#rompre9custodyo%erdoseshadbeenchec&edmore#re(uentlythantheother detainees!Table4"' Thissuggestedthatinsomeinstances-custodyofcersh ad alreadyrecognisedthesedetaineesmightbe.atris&/'

Table4also indicatestha tdetaineeswho died #romincustody3+H werechec&ed l e ss#re(uentlythan all the otherdetaineeswhodied' Thiswascon5rmedby the 5nding thattheinter%albetween the las tchec& andthe detainee being #ounddeador dyingwas greater#orincustody3+H cases than #oranyother ca tegory'

"a1le:"he;.S#dea)hs:0reAue&co0chec%s

Pre9custody3+H 6n9custody3+H *llcustodydeaths

?%eryhour $9: FN: $$:

?%eryhal#hour 1G: FN: GF:

@ore#re(uently F4: $9: $4:

Constantsuper%ision $1: 2: 12:

This impliedthat thesepeoplehad notbeen recogn isedas .at r is&/E and the less #re(uentchec&ing mayha%eal lowedthem moreopportunitytoharmthemsel%es' 6tis no tc lear-howe%er-howthismight bes tbe addressed>


36/109


37/109

6na#ewo#thepre9custodyo%erdosecases-ofcersdidnotapparentlyreacttosigns thatadetaineemightre(uiremedicalattention' Onedetaineewhodied#roman o%erdose-#ore,ample-re(uestedanF@?butofcersdidnotcontactone-as re(uiredbyP*C?Codeso#Practice-becauseheapparentlyrapidly#ellintoadeep sleep' Onanotheroccasion-ofcersapparentlynotedthatthedetaineehad %omitedwhilstasleep-butdidnotreactuntilhewasseennottobebreathing'Thesemayre)ectsomeerroro#7udgementontheparto#theofcers-or#ailingsin theguidancegi%entothem' Howe%er-itneedstoberememberedthatitis probablyrelati%elycommonplace#ordetainees-whodonotgoontodieincustody- toasoradoctororto%omit'

Thestudyalso#oundthatoncethedetaineewasrecognisedasbeinginneedo# medicalattention-policeofcerswererecordedasreactingimmediately-bycalling #oradoctororambulance' Theywerealsorecordedasha%ingattemptedto resuscitate$$:o#thedetainees#oundcollapsedorhanged' Howe%er-6Os/records seldommentionedresuscitationattemptsanditmaybethattheactualnumberwas higherthanwecouldidenti#y' *lthoughtheresuscitationwasunsuccess#ulinthe caseswee,amined-theyunderlinetheimportanceo#alwaysha%ingcustodysta## a%ailablewhoha%ebeentrainedin5rstaidandresuscitationtechni(ues-andto ha%ea%ailablethee(uipmenttheyneedtoper#ormtheseactions'

TH? 3?C?*+?3/+ O= *CT6O+ +DA+T*C? *AD+? *3 *CC63?T+


38/109

TH?3?C?*+?3/+O=*CT6O+E+DA+T*C?*AD+?*3*CC63?T+

4"hedeceased5sow&ac)io&s6su1s)a&ce a1use a&daccide&)sSu1s)a&cea1use

=ithinthisstudy/s.deceased/sownactions/category-substanceabusewasthe secondmostcommonsub9category-representing49cases!$N:o#allthedeaths"'Thebrea&downo#thesecaseswasas#ollows>

6nGNcasesthedeceasedhadconsumedalcoholonitsown' @anyo#these probablyhadunderlyingmedicalproblemswhichcontributedtotheirdeaths'

6nF9cases-howe%er-thepathologist/sreportmadeclearthatacutealc o ho l ismIor alc o ho lpo i soiI1had beena&ey#actoreitherasthesolecauseo#deathorone thatspar&edanothercausesuchasaheartattac&' 6na#urthersi,cases-the indi%idualdied#romaspi rati o Iorasphy3i at i o +ro mth ei h al at i o o +-oIm i t broughtaboutbytheirdrun&encondition'

6nsi,teencases-thedeathwasadirectconse(uenceo#dru's '*lthoughsome mayha%ebeendisguisedsuicideattempts-thee%idenceimpliesthat-in#ourteen cases-thecausewasunintendedpoisoningEeither#romano%erdoseorthe mi,ingo#drugs' 6noneothercase-withdrawalwasa&ey#actorandinanother asphy,iation#rom%omitcausedthedeath' @ethadone-inparticular-wasa #actorinsi,deathswhilstecstasy-amphetaminesandProthiaden

!dothiepin" #eaturedinthreeothers'

6neightcases-thedeceaseddied#roma(i+)ureo0alcohola&ddru's ' 6ntwoo# thesecases-theactualcauseo#deathwasasphy,iation#rom%omit-butinthe othercasesthedeathcerti5caterecordedcombinedpoisoningsasa&eycause'Thedrugsin%ol%ed-whereidenti5ed-tendedtobethosethataremoreregularly a%ailablethroughpharmacistsor#romdoctorsEsuchas3istalgesic!co9 pro,amol"-temaKepam-diaKepamandmorphine'

6tshouldalsobenotedthatalcoholmayha%eplayedapartinmanymoredeaths thanthosecountedabo%e' Forinstance-manypeoplewhodied#romamedical conditionapparentlysu8eredthatconditioninpartbecauseo#pastalcoholabuse' 6naddition-post9mortems#oundthattwothirdso#thedetainees

includedinthis studyhadconsumedsomealcoholbe#oretheydied' Ourdiscussiono#alcoholasa directcauseo#deaththere#orealmostcertainlyunderestimatesthein%ol%emento# alcoholasacauseo#custodydeaths'

*s w iththe p recustody3+H o%e rdoses-manyo#thesesubstanceabuse caseshad already.lit the#use/be#orethey had been ta&enintocustody>thesubstancestheyhad abused wou ldha%e puttheirli%esat ris&whethertheyhad been

TH? 3?C?*+?3/+ O= *CT6O+ +DA+T*C? *AD+? *3 *CC63?T+


39/109

TH?3?C?*+?3 +O=*CT6O+E+DA+T*C? *AD+?*3*CC63?T+

detainedbythepol iceornot' *gain-how e%e r-thereare lessons #romthese deathsandtheseare e,plored below'

War&i&'si'&sa))hepoi&)o0de)e&)io&

Poss iblewarningsignsthat a detaineemig htsu8erthe e ##ec tso#substance abuse inc ludedt heail m e tImar&eron thePC'Thismar&ercouldpotential lywarncustodysta##that a de ta ineehad p re%iouslybeen recordedas abu singa lcoholor drugs-oras a glue sni##er' 6n thecases we

e,amined- howe%er-such warningswere rare>

Thealc o ho l iIcwarningwaspresentonthePCinonlyonecaseinourstudy' Thissuggestedthat-despitethelargenumberso#indi%idualsarrested#re(uently #orbeing36-drun&detaineesaresocommonthatcustodyofcersseldom thin&it.right/orworthwhiletorecordthemonthePC'

Thed ru1 sIwarningwaspresentmoreo#ten>$1indi%idualsinthisstudyhadthis ontheirrecords' Howe%er-onlysi,o#thesedied#romdrugsabuse'

ThissuggestedthattheCd ru1 sDwarningwasnotaparticularlyreliablesign#orthissort o#deathEparticularlysinceitspresenceonthePCmay-moreo#ten

than

not- ha%e

re)ected

the

possibility

that

the

detainee

mightp re se t

a

risk

to ofic e r-s rather

than

be

.at

ris&/

#rom

drugs

themsel%es' 3rugs

warnings

on

the

PC

mightalsobere#erringtothepastpresenceo#drugsthatwerenotnecessarilya greatdangertothedetainee/shealth'

Theseofcialrecordsthere#orehad%erylimited%alueinhelpingthepolice identi#yindi%iduals.atris&/o#substanceabusedeaths' Ofcersmustthere#orerely ontheirassessmento#thedetainee/sphysicalcondition'

This-howe%er-alsoposedproblems' Forinstance>

*greatmanydetaineeswhoappear%erydrun&passthroughthecellswithout incidentEsoe,tremedrun&ennesso#itsel#isunli&elytosignalthatan

indi%idualmaydie'

=ithsomanyapparentlydrun&detaineespassingthroughcustodyitisdifcult #orcustodysta8tobealerttothe%erysmallnumbero#caseswherethere

maybe aproblem' Theonlywayis#orthemtoensurethattheyalwaysgothroughthe proceduresandassesstheconditiono#e%erydetaineenomatterhowroutinethe situationseems'

3rugabusecanalsobemista&en#ordrun&enness'Fore,ample-nearlyhal#o# thosedying#romdrugsabuseinourstudywerearrested#orbeingdrun&-

despite

TH? 3?C?*+?3/+ O= *CT6O+ E +DA+T*C? *AD+? *3 *CC63?T+


40/109

TH?3?C?*+?3 +O=*CT6O+ +DA+T*C?*AD+?*3*CC63?T+

mosto#them o tha%ingconsumedalcohol' Ofcersmaythere#oreassumea detaineeismerelydrun&-andpotentiallymissmoreseriousdrugsabuse'

Hence-adetainee/sapparentphysicalconditionmayo#ten#ailtoindicatemore seriousproblems' Thisalmostcertainlyma&esitdifcult#oracustodyofcerto identi#ythoseatgreatestris&'

3espitethesedifculties-ofcersdidnotethemedicalurgencyo#manyo#the cases-andreactedpromptly' 6neighto#the49substanceabusecases-ofcers#eltthedetainee/sconditionwassoserious-theywereta&endirectlytohospital-rather thantothecustodysuite' *#urther#ourdetaineeswerere#erredtohospitalimmediatelyonarri%alatthecustodybloc&' The#actthatthesetwel%epeoplestill diedillustratestheprecariousphysicalstateo#someo#thedetaineesthepolicehad todealwith'

Our5ndingsalsohighlightedse%eralsituationstowhichcustodyofcersshouldbe alert' Fore,ample>

6nmosto#theNFcasesin%ol%ingalcohol-thedetaineeswereanonymouswhen ta&enintocustody-and#ewweregi%entheirrights-inter%iewedorcharged !Table8"$2' 6nstead-inmanycases-thedeceasedwererecordedassimplyha%ing beenpl ace di ac eIl lapparentlytosleepo8thee8ectso#thealcohol-and presumablybecausetheyweretooin)uencedbyalcoholtopro%idein#ormation orunderstandtheirsituation'

6n add ition-a (uartero#theseindi%idualsweretoodrun& towal&'+i,hadc o l l ap se dIin the street-and eightwe reu a, l etostaIdandhad to bec arri e dIintothe custody bloc&' *#urther#ou rwere le #tinthe irc el lsinthereco%erypos i tion'

906maycase s7o +co urse72h eerth edetaiee 2assimply druk th e

police 2ouldot h a-eiteded t o

i t e r-i e 2th emay2a.y

"a1le8: "he;su1s)a&ce a1usecases:)rea)(e&)i&cus)od

*nonymous Rightsgi%en 6nter%iewed Charged

*lcohol9relateddeath N9: 0: N: N:

3rugs9relateddeath $1: F4: $F: $2:

*lcoholanddrugs9relateddeath 40: 2: 2: 2:

Othercauseo#death $$: G9: $F: 19:


41/109

6ncoherentandinsensibledetaineesarecommoninmanycustodybloc&s' Howe%er-itisimportanttoac&nowledgethatthesecharacteristicsmaymas&moreseriousdrugandalcoholproblems' 6tisworth-there#ore-remindingcustodyofcersthattheyshouldbeparticularly%igilantwithsuchcases-untilthedetainee/s physicalstatehasbeen#ullyassessed'

*secondpointisthatmanyo#thosearrested#ordrin&9relatedo8enceswere already&nowntocustodyofcersashabitualalcoholicsLinmanycases-therecords

notethatthedeceasedwasak o2

re 1ul ar

d ruIk' 6tispossiblethatofcersmay betemptedtobeless%igilantwithoneo#their.regulars/'Custodysta8shouldbe awareo#thisris&andguardagainstit'

Finally-thestudysuggestedthatdetaineeswhodied#romdrugsabusegenerally becameillmorerapidlythanthosewhodied#romalcohol' Thishighlightedtheneedtoidenti#ydrugsabusedetaineesas(uic&lyaspossible-be#oretheyareplaced inacellwheretheirconditioncandeterioraterapidlyunnoticed' *swenoted earlier-identi#yingdrugsabusecanbedifcult' Howe%er-thepresentstudy identi5edcaseswherepossiblewarningsignsmayha%ebeenmissed>

onethirdo#thosewhodied#romdrugshadpre%iouslybeenincustodyandwere &nownusersLand

inonecase-whenarrested-thedetaineepossessedhal#abottleo#whis&ey-anda large(uantityo#medicinesanddrugs'

3istinguishingthegenuinely.atris&/#romthosewhoaremerelydrun&isne%er li&elytobeeasy' Theabo%ee,ampleshighlighttheneed#or%igilance-particularly intheearlystageso#detention-whenthedetainee/sphysicalstatewilline%itablybesomethingo#anun&nown(uantity'

2hec%i&'de)ai&eeswhils)i&cus)od

*lcoholisonlygraduallyabsorbedbythebody-soitsworste8ectsmayonlyoccur sometimea#teradetaineehasbeenplacedinacell' Forthisreason-

there%ised P*C? Codeso#Practicere(uiredrun&detaineestobechec&edandrousede%ery hal#hour' Thee%idencesuggeststhat-inthema7orityo#caseswhereadetaineehadbeenarrested#oranalcohol9relatedo8ence-thepolice2e regenerally#ollowing theCodes!Table9">9F:o#thesedetaineeswerebeingchec&edatleaste%eryhal# hour'Thenewre(uirementtorousedetaineesdidnotcomeintoe8ectuntil*pril199N' Therecordssuggested-howe%er-thattherewaslittledi8erenceinthe proportiono#detaineesinoursamplewhowerebeingrousedbe#oreanda#terthe change>NN:o#36detaineeswhodiedbe#ore*pril199Nwerebeingroused-


42/109

comparedwith4$:a#terthenewre(uirement' 6tiseasytoimaginewhycustody sta8mightnotha%etimetorousee%eryapparentlydrun&detaineeand-indeed- mightpre#ertoletthem(uietlysleepo8thee8ects' e%ertheless-therewerea #ewcaseswhereadyingdetaineemightha%ebeen#oundearlierhadtheybeenchec&edmore#re(uentlyorroused' Failuretorouseadrun&detaineeisabreacho# boththeP*C?Codeso#Practiceand#orcedisciplineand-in#ourcases-ofcers weredisciplined-ad%isedoradmonished#ornotha%ing%isiteddetaineesmore #re(uentlyandnotrousingthem'6noneo#thesecasesthepathologistput

the detainee/stimeo#deathasatleasttwohoursbe#oretheyweredisco%ered>the custodyofcerhadchec&edbutnotrousedhim'

"a1le;:"he;su1s)a&ce a1usecases:0reAue&co0chec%s

*rrested#or drin&relatedo##ence

3eath#rom alcoholabuse

3eath#rom drugs abuse 3eath#rom abuse o#alcohol anddrugs *ll custodydeaths

?%eryhour 0: 1F: 2: 1G: $$:

?%eryhal#hour 4N: 4F: 01: GF: GF:

@ore#re(uently $$: $G: $9: $9: $4:

Constantsuper%ision 4: 2: 2: 1G: 12:

Roused N4: N0: N4: 82: N0:

Fromthein#ormationa%ailable-itwasnotclearh o2ofcersrouseddetaineesE whethertheyenteredthecellandspo&etoorphysicallymo%edthedetainee-or

thesorto#response#orwhichtheywereloo&ing' TheP*C?Codeso#Practicedonotde5nethemeaningo#torouseInor#orwhatsignsofcersshouldbechec&ing'TheCodesdo-howe%er-re(uirecustodyofcersimmediatelytosendtohospitala detaineewhodoesot sh o2si1s o +se si ,i l i t yo ra2are I'e ss6tisli&elythat guidanceonhowtorouseandhowto7udgeadetainee/sconditionwouldbeo# %aluetoofcers' Oneoptionmightbethede%elopmento#protocolsrelatingto detainees/di8eringstateso#consciousnessandhowofcerscouldinterpretand reacttothem'TheP*C?Codeso#Practice$1alsore(uirecustodyofcersimmediatelytocallanF@?i#adetaineeapp e arsto ,e sufe ri 1+ro mphysic ali l l ess orametalc o d i t i o Go ri si 8 ured Go r+ai lsto re sp o d o rm al lyto.ue st i o so r co-ersatio (ot h e rth athrou1 hdrukeess al o e)Go rot h er2 iseappears to eed

9%P!*E

*odes

o +

Prac t i c e7

*od e*&.9.

medicalat t e t iIo' Protocolsandpro#ormasmighthelpcustodysta8-whenrousingapparentlydrun&detainees-7udgemoreaccuratelywhethertheyaresu8ering#rom drun&ennessaloneLwhetherthedetainee/sconsumptiono#alcoholhasplacedtheir


43/109

li#eindangerLorwhethertheymightbesu8ering#romsomeothermedical condition!whichmayha%ebeenmista&en#ordrun&enness"' Protocols-howe%er-shouldnote8ecti%elyre(uirecustodysta8topro%ideamedicaldiagnosisEthey shouldaim-instead-tohelpofcersdecideas(uic&lyaspossiblewhetheradetaineere(uirespro#essionalmedicalattention' Theissueo#themedical treatmento#detaineesisreturnedtoin+ectionsNand8'

6nmostcases-the5rst signthat adetainee wasillwasthatthey were ha%ing trouble breathingorappeared toha%e stopped breathing' 6nthisconte,t-itshouldbe

noted thathea%y snor ingcanbeanearlysigno#breathing problems-because itsigna lsa partia la irwayobstruction'Forinstance-insi,cases inthisstudy-hea%y snoringwas recordedasasignthatthedetaineewasasleepandper#ectly wellLhowe%er-these indi%idualsweresubse(uently#ound notbreathing'Thecasesreportedalmost certainlyunderrepresentedthetruenumber where the detaineewassnoring'=edid notstarttochec&therecords#orthissignuntilpartwaythroughthedata collection!when its#re(uencyhadbecome apparent"andthenwe#ound that6Os/ reportswereseldomsufciently detailedtoinc ludesuch in#ormation'

Thedeathswee,amined-there#ore-underlinedtheneed#orcustodyofcers physicallytorouse.drun&/detaineesEespeciallythosewhoha%ehadtobecarriedtothecell-andthosewhoarebreathingloudlyorsnoring' Howe%er-thedifculty inidenti#yingproblemsshouldnotbeunderestimated' *(uartero#the

detainees e,aminedbyF@?shadbeenconsidered.5t#ordetention/Eindeed-twoo#them wereseen#ourtimesandstill7udgedtobewell' 6#doctors#ailedtospotdanger signsorappreciatetheirsigni5cance-itisnotsurprisingthatcustodyofcersalso sometimesmissedthesignalsor-perhaps-#oundithardtoo%erruleanearlier medicalopinion' Thereisaneedtoensurethatnotonlycustodysta8-butF@?s too-areawareo#thedangersignsandhowtoreact'

Policeac)io&so&disco,eri&'su1s)a&ce a1usedea)hs

O#the49detaineeswhodied#romsubstanceabuse-FGwere#oundintheircell eitherdeadorcollapsed' Oneapparentsigno#distress-commontosomeo#those #oundcollapsed-wasbleeding#romthenoseandmouth'

6n mostcases where the deta ineewas clear lydead- thepo l iceca ll edan F@? to con#irmthedeath-althoughin a #ew cases theywere also recordedasattemp t ingre suscitat ion!Table12"' =herethedetaineewas st i llal i%e-inthe ma7or ityo#cases o8icerswere recordedas cal l ing#oran ambu lance'6nmany cases theyalsoattemp tedre suscitat ion!e,actnumbersareunc learbecause o# incomp leterecord&eeping E althoughtherecordssuggestedthat o##icerstr ied resusc i tat ionin at least19 subs tanceabuse deaths"'


44/109

"a1le10: Su1s)a&cea1use cases:recordedpoliceac)io&so&0i&di&'de)ai&eesdeador collapsed

*lcohol abuse 3rugs abuse *lcoholand drugsabuse *llsubstance abusecases

Totalnumbero#caseswheredetainee #oundcollapsedJdeadintheircell $N1 4 F FG

E policere(uestedambulance 10 4 F $4

E policeattemptedresuscitation 1F F F 19

ote>1 3ataonhowthepoliceactedweremissing#or#ouro#thesecases'

6na#ewcasesthedetainee/sconditionwasapparentlyserious-butcustodysta## wererecordedascalling#oranF@?5rst-notanambulance' 6n#ourcasesthe detaineewasapparently#oundcollapsedunconsciousand-inanothertwocases- ha%ingdifcultybreathingLineachcaseofcerscalledanF@?-

whointurnad%isedre#erraltohospital' =ecouldnottell-inthesecases-whetherofcerswere #ollowingor#ailingto#ollow#orceguidance-orwhethertheyhadrecei%edpoorguidanceornoguidance' Thereiso#tenli&elytobea5nelinebetweenwhethera detainee/sconditionissoseriousitre(uiresanambulancetobecalled'*rguably- howe%er-caseswhereadetaineecannotberousedorwheretheycannoteasily breathere(uireemergencyattention'

Finally-itisworthnotingthato#allthesubstanceabusedeaths-G$:diedin hospitaloranambulance-whiletheremainderdiedinapolicestationor%ehicle!Table11"' 6tisperhapsarguablethati#someo#thedetaineeshadbeenplacedin medicalcaremoreswi#tly-theymightha%esur%i%ed' Howe%er-whilethepreceding discussionnotedsomeareaswherethepolicemightha%eacteddi8erently-italso notedthepoorhealtho#manyo#thedetaineeswhodied#romsubstanceabuseand thedifcultyinidenti#yingthosemost.atris&/' 6tisparticularlyhard#orcustody sta8toidenti#ythesepeopleagainstabac&dropo#alargenumbero#%erydrun& indi%idualspassingthroughthesystemwithoutincident'

"a1le11: "he;su1s)a&ce a1usecases: loca)io&o0dea)h

*lcohol abuse!nGN"

3rugs abuse!n14"

*lcoholand drugsabuse!n8"

*llsubstance abusecases!n49"

6n

hospitalJambulance19 4 G $9

6npolicestationJpolice%ehicle $4 12 G G2


45/109

$ccide&)swhils))hepolicewereprese&)

Thisisthe5nalcategorywherethedeceased/sownactionsapparentlycontributed totheirdeath' Thisstudyidenti5edtenpeoplewhodiedinapparentaccidentsbe#ore-duringora#terthepolicetoo&themintocustody' 6neachcase-they apparentlyactedinawaythatledto#atalin7uries-butinnocasewaspoliceaction reportedtobeanassociated#actor!suchcasesareconsideredin+ection4"' 6n se%eno#thetencases-theindi%idualdiedasaresulto#in7uriessustained#roma#all' 6ntheremainingthreecases-theindi%idualaccidentallyswallowedcocaineor heroinwhilsttryingtoconcealthem' =eincludedthesethreecasesinthiscategory-ratherthanas3+Horsubstanceabuse-becauseonbalanceitappeared thatthedetaineehadnoti t e d etdosel#harmoringestthedrugs'

i%entheiruni(uecircumstances-thesecaseso8ered#ewgeneralisablelessons'=e ha%e-howe%er-brie)ysummarisedthetendeaths!Ao,"'Theonly#actorthat appearedcommontoama7orityo#thecaseswasthatthedetaineemayha%ebeen attemptinganescape#romcustody' Therecordssuggestedthatarrestingofcers shouldremainalerttothepossibilitythatsomedetaineesmightreactbyta&inga courseo#actionthatplacestheirli%esindanger' 6n mostcases-therecords

impliedtherewaslittlethepolicecouldha%edonetoa%oidthedeathEitwasnot ob%iousthattheaccidentcouldha%ebeen#oreseenoreasilypre%ented'Furthermore-inthosecaseswhererecordse,isted-thepoliceapparentlyreacted promptlybycalling#oranambulanceorta&ingthedeceaseddirectlytohospital'


46/109

Bo+.:$ccide&)swhils))hepolicewereprese&)

2ase1> 3etaineearrestedonwarrantwho#ellwhilst wal&ingalongacellpassageway-su##ering a#atal headin7ury'Theyhadconsumedalcoh olandwere&nown tobeanalcoholicwhohad in7uredthemsel%esse%eraltimesbe#orewhen drun&'

ase2 > *detainee arrested#or drin&dri%ing di%edhead#irst#romthepolice%ansoona#terit le#t thescene- su##ering #atalheadin7uries' Thepersonhadlittleregard#ortheirsa#etybecause theyhadt riedto&illthemsel%es bydri%ingintoawall' Thedetaineehad notbeenhandcu##ed andthe 6Orecommendedchangesto#orcerestraint policyandtheloc&son

%ans'Sote>we categorised thiscase asanaccident- ratherthan3+H-becausealthoughitwaspossible that the detaineeintended toin7urethemsel%es itwasnotclearthattheiractions did notsimply representanattempt to escapecustody'

2ase. > *detaineeheldincustody #or burglaryescapeda#terbeingta&entotheirhome #or en(uir ies'Thepersonwaspursued toa#riend/sse%enth#loor#lat#romwhichthey#elltothei r death a#terclimbing outo#thew indowandtryingtoscale downtheoutside'The recordsdo notstatewhetherthedeceased-a&nowndrugsuserwho hadconsumeddrugsshortly be#ore theirarrest-wasrestrainedduringthe%isitbutitseemedunli&ely-#romtherecords-thatthe person washandcu##ed'

2ase4 > *personwanted #orburglarywasrecognisedbyano##icer-pursuedtothese%enth)oor o#acarpar& and#oundclinging toaw iremesh#encebe#ore #allingto theirdeath'Thedeceasedwas&nowntobementallyillandhadalonghistory o#suicide attemptsandsel#harm'

ase7 > *person accidentallyswallowed a#atal(uantityo#cocaine a#terputting three wraps in theirmouthduring adrugsraid'Thedetainee wasseentobebleeding #romthemouthand o##icersremo%edapiece o#wrapbutmistoo&i t#orpart o#thedetainee/stongue'Thepersonwaslater#oundtoha%ehadthreewrapsintheirmouth'

2ase > *nindi%idualwhom policetriedtoarrest#orthei rownsa#ety escaped#romthepolice %an-7umpedasa#etybar rierabo%eamotorwayand#el ltotheirdeath'Theperson-aglue sni##er-wasbeingarrested becauseo#theirmentalcond ition'They apparently hadsaidto othersthattheywere1o i1to,e takea2ayi a-a ad 2ouldco m e, ackassom e ,odyI-ebl suet therecordsdonotma&eclearwhether thepolicewereawareo#theperson/s mentalstate'

ase/ > *nin7ureddetainee arrested at thesceneo#aburglary-ha%ing #allenthrough theroo#- wasta&entohospital wheretheyattemptedtoescape andsu##ered#atalin7ur iesa#ter#alling#roma#irst)oorwindow'Thepol icewereapparently present atthehospitalbuthadde9 arrestedthedeceased and- presumably-notrestrained them-toa-oid a,ed2atcIh'

2ase8 > *detaineearrested#orsuspectedpossessiono#drugsdieda#ter7umping throughthe openwindowo#aneighth # loor#lat'Thedeceased-whohadta&endrugsshortlybe#orearrest- hadal readyattempted toescape' Theperson7umpedthrough thewindow despite ha%ingbeen handcu##ed'

ase; > *detaineewasstoppedinthestreetand(uestionedbyo##icersaboutsuspected possession o#drugs' Theydied a#terswallowingabago#cocaine'

2ase10> *detainee-a#terbeingarrested#ordri%ing under thein#luenceo#drugs-swalloweda pac&o#heroin'*&nowndrugaddict- theyapparentlygrabbed andswallowedsomeo#the heroina#ter being placed inthepolice%an' *nF@?declaredthedetainee .#it#ordetention/- butthepersonwaslater#oundcollapsedinthecell'The6OnotedthatP*C?waso tasstri1e Itw ithdrugsaswithalcoholandthat cl o se rm o i to ri 1...mayh a-eh i 1hli 1hte dJth epesrKso "d e t eri orat ioearliIe rEbutthatthiswasprobablybeyondtheabilitiesorroleo#thepolice'

TH?3?C?*+?3/+@?36C*;CO36T6O


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7"hedeceased5s(edicalco&di)io&

+ectionsFandGloo&edatdeathsapparentlycausedbythedeceased/sownactions'Thesecondlargestgroupingo#causal#actorsrelatedtothedetainees/medical conditionsasrecordedinthedatawestudied' +e%ereorchronicmedical conditionsapparentlycaused81deaths-or$9:o#thetotal' 6nmanyo#these cases-thedetainee/sconditionwasprobablyrelatedtolong9termbeha%iours-such asalcoholism'Thesedeathsdi8ered#romthosedescribedinthelast+ectionbecausetheycouldnotbeconclusi%elyassociatedwithanydeliberateactionsta&en bythedeceasedshortlybe#oretheirdeath>instead-theconditionsimplypro%ed

#atal

whilst

the

deceased

was

in

custody' Two

conditions-

in

particular-

were common>

heart

problems

and

head

in7uries

!Figure1"'

Fi'ure1:!edicalco&di)io&sas)he%ecauseo0dea)h=&81>

@isc'conditions9:

;i%erproblems G:

?pilepsy N:

;ungproblems12:

Headin7uriesFF:

HeartproblemsF9:

*part#romthe#ourpeoplewhodiedasaresulto#epilepsy-thedetaineesdying #rommedicalconditionswereconsiderablyolderthaninothercases

!Table1$"'

@any

o#

them

had

been

arrested

#or

alcohol9related

o8ences' 6mportantly-

howe%er-

1998 uk home office - deaths in custody lessons

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