Independent Office for Police Conduct (IOPC - formerly IPCC)
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IPCC publishes findings from major study into 333 deaths in police custody

A major Independent Police Complaints Commission (IPCC) study of 333 deaths in police custody published recently reveals a welcome, substantial fall in the number of deaths over an 11-year period, and puts forward actions for police forces and health service providers to help prevent further tragedies.

In the first year of the study (1998/99) 49 people died in police custody in England and Wales, but by the last year (2008/09) this had fallen to 15. The long-term study gathered information about all the deaths in custody between 1998/99 and 2008/09, including personal characteristics of those who died, medical factors and the circumstances of their arrest, to identify themes.

The research found that potential factors contributing to the reduction include better police cell design with fewer ligature points, ill detainees being taken to hospital rather police custody, and better use of restraint techniques.

However, in just under half of the cases police failed to carry out a required risk assessment, and also prevalent were incidents where custody officers had not conducted proper checks or rousing of detainees. The study found that in many of the cases custody officers and staff lacked basic first aid training.

Alongside the research, the IPCC is also publishing today its annual statistics on deaths during or following police contact which show that the number of deaths in custody in 2009-10 rose to 17, the first increase in six years.

IPCC Commissioner Mike Franklin, who leads on custody matters, said:

"Every death in custody is a tragedy that leaves families desperate for answers and has the potential to seriously undermine the public's confidence in the police. This piece of research gives substantial insight into some of the most controversial and important work the IPCC is responsible for.

"There has been a huge focus from all involved in policing to successfully reduce over time the number of deaths in custody, but as the small rise in deaths in 2009-10 shows we can not be complacent. We owe it to the public and police that lessons are learned from the traumatic experiences of others. There are still areas where we have identified major concerns and we have put forward practical recommendations for police, together with health service providers, to help prevent any unnecessary deaths.”

Findings from the study include:

  • The most frequent characteristics of those who died were that they were white (75%), men (90%) aged between 25 and 44 (48%). On average they were 39 years-old.
  • The ethnic breakdown was as follows - 76% white, 7% black and 5% Asian - representative of the general ethic make up of the custody population.
  • Approximately three-quarters of those who died had a link to drugs and/or alcohol, in that they were intoxicated, had been arrested for alcohol and/or drug related offences, or the cause of death was related to alcohol and/or drugs.
  • On average there were 2.2 deaths per 100,000 notifiable arrests, a figure that ranged from 3.6 in 1998/99 to 1.0 in 2008/09
  • In the first year of the study there were 15 suicides , but this fell to 3 a year in the rest of the period the study looked at. This appears to correlate with the beginning of work to make custody suites safer. Previous Home Office research found that between 1990 and 1996 172 deaths in custody (63%) had been caused by 'deceased own actions', including 73 hangings.
  • 58 people had mental health issues, including 17 who were detained under section 136 of the Mental Health Act.
  • Of the 87 cases where restraint was used on a detainee, it was linked to the death on 16 occasions.
  • Less than half of detainees that were booked into custody and should have been risk assessed were actually risk assessed.
  • In 87 cases misconduct action was recommended for police officers/staff and 13 officers were charged with criminal offences.
  • Over the period of the study no officers have been convicted of any offence in relation to the death of detainee. One police member of staff received a six-month sentence of imprisonment for misconduct in public office.

Mike Franklin said:

"The public focus on deaths in custody has understandably been on the controversial cases where the police may have caused or contributed to someone's death. While there were some cases in the study where police failings were identified - principally involving restraint or neglecting their duty of care - these were relatively small in number.

“What emerges most prominently from the report is the medical and mental health needs of a large number of people the police arrest. The study highlights a number of questions about custody which must be addressed if further progress is to be made. Chief among these is whether custody, as it is in police stations up and down the country, is actually the best place for a large number of people the police deal with.

“As a high number of people with medical and mental health needs will inevitably find their way into police custody, we need better collaboration between police forces and the NHS to ensure the right healthcare is available. We are reiterating our call for the NHS to provide more alternative places of safety, and for police forces to ensure sufficient forensic physicians are available to carry out mental health assessments."

The study found that there was still work to be done by police forces to improve the number of risk assessments that were carried out and the thoroughness of checks and rousing of detainees. The Police and Criminal Evidence Act (Code C) states everybody who enters custody should be risk assessed, however the study found that in the 247 cases where a detainee had been booked into custody, only 121 were risk assessed.

Similarly despite guidance saying rousing should elicit a response, the most common method used for rousing a detainee was simply going to the cell. This happened on 36 occasions.

Mike Franklin concluded:

“To prevent unnecessary deaths it is essential every single officer or member of police staff are aware of the potential risks and responses needed. That starts with a call taker getting as much information as possible about potential medical issues, arresting officers being aware of the potential harm restraint can cause and then making sure colleagues in custody are given comprehensive briefings; through to custody staff giving detailed handovers and thoroughly rousing those in cells. As the study shows it only takes one of the links in the chain to fail for the chances of someone dying in custody to increase.”

Annual Death Statistics

In 2009/10 there were 86 deaths during or following police contact, of which:

  • 29 were road traffic fatalities;
  • 2 were fatal police shootings;
  • 17 were deaths in or following police custody; and
  • 38 were other deaths following police contact.

In 2008/09 there were 93 deaths. The drop in deaths is mostly attributable to the number of fatal road traffic deaths falling from 40 to 29. There was also one fewer fatal shooting.

The number of fatal road traffic incidents fell by seven, from 33 in 2008/09 to 26 in 2009/10, resulting in 11 fewer deaths. The number of incidents this year is the second lowest figure recorded since 2004/05. The number of pursuit-related incidents has increased by one compared to the previous year to 17 incidents. This is the third lowest number of pursuit incidents since 2004/05.

IPCC Interim Chair Len Jackson said:

“The numbers of deaths involving the police fell last year, mainly as a result of a drop in the number of fatal road traffic incidents. Over the last few years this figure has fluctuated, most notably in the 2008/09 when we saw a substantial rise after a period of welcome decline.

“The fall in the number of deaths in custody over the last few years is down to the concerted efforts of everyone involved in policing. The same focus and determination to make the changes we feel are necessary is not something we have experienced in relation to road policing. We may have seen a fall this year but we are clear that there is still work to be done and we will be continuing to push for a mandatory national policy.”

Copies of both reports can be found here:

Deaths in Custody Study:

Annual Deaths following or during police contact report 2009/10:

Notes to editors

Deaths in or following police custody includes deaths of people who have been arrested or otherwise detained by the police. It includes deaths which occur whilst a person is being arrested or taken into detention. The death may have taken place on police, private or medical premises, in a public place or in a police or other vehicle.

This would include the following:

  • Deaths which occur during or following police custody where injuries which contributed to the death were sustained during the period of detention.
  • Deaths which occur in or on the way to hospital (or other medical premises) following or during transfer from police custody.
  • Deaths which occur as a result of injuries or other medical problems which are identified or develop while a person is in custody.
  • Deaths which occur while a person is in police custody having been detained under section 136 of the Mental Health Act 1983 or other legislation.

This would not include the following:

  • Deaths (including suicides) which occur after a person has been released from police custody, except where they meet the criteria outlined above.
  • Deaths of individuals who have been transferred to the care of another agency and subsequently die while in their care.

Research Methods:

The research used investigation reports and inquest verdicts, as well as other information such as misconduct recommendations on completed cases, as the basis for collecting information on these incidents. These sources of information provide the most thorough and detailed evidence available on the deaths and bring together a wide range of information such as custody records, toxicology reports, and CCTV evidence, although they do not all provide the same extent of information.

The study had an expert group who oversaw the project, providing comments and advice. This consisted of representatives from the Association of Chief Police Officers, the Home Office, the Department of Health, and the National Policing Improvement Agency, the Faculty of Legal and Forensic Medicine, and an independent academic.

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