APPENDIX
DEATHS IN CUSTODY—AN ANALYSIS OF POLICE-RELATED
DEATHS IN HOME OFFICE CATEGORIES 1, 2 AND 3 BETWEEN APRIL 1998
AND MARCH 2003
Dr David Best
Police Complaints Authority
19 September 2003
BACKGROUND AND
RATIONALE
From 2 October 2000, the Human Rights Act 1998
was incorporated into UK law, including Article 2 on the "right
to life" stating that "Everyone's right to life shall
be protected by law". The report below attempts to address
issues around the right to life and its manifestation in police
custody and broader contact between the police service and the
general public, to examine the main causes of deaths in custody
and underlying common factors in the context and characteristics
of these deaths. One of the main emphases of the work will be
on vulnerable populations, in the context of suicide, and in relation
to ethnicity as an indicator of increased likelihood of custody
death.
According to Home Office data, just under 1.3
million people suspected of committing an offence are arrested
every year. In 2001-02, of this 1.3 million arrests, 97,800 (8%)
were recorded as being black, 55,600 (4%) as Asian and 11,800
(1%) as being of other "non-white" groups. This represented
a rise of 7% for Asian and 12% for black arrestees when compared
with the previous year.
However, among all ethnic groups, death in custody
is an exceptionally rare event, with the PCA Annual Report (2003)
indicating that there were a total of 27 Category 3 custody deaths
(see below for definition) in 2001-02 and 30 such custody deaths
in 2002-03. Although the periods of assessment are not directly
comparable, this means that there are slightly more than two deaths
per 100,000 arrests in England and Wales.
However, every such incident is a tragedy and
is investigated accordingly. This investigation will be undertaken
by the professional standards department of the police force in
which the incident occurred or, on occasion, of an independent
force. All of the deaths included in this analysis have also been
supervised by an independent oversight body, the Police Complaints
Authority (PCA).
The PCA has previously attempted to address
this issue in two linked reports (1999). The first of these highlighted
risks around custody and made recommendations to address a number
of risk factors with the follow-up report identifying successes—a
success that is evidenced in the reduction in custody deaths over
the course of the 1990s.
The PCA is in a unique position to assess police-related
deaths through its supervision role, by which all deaths involving
the police are referred voluntarily by the relevant force for
supervision of the investigation. The PCA file therefore is based
on the police investigation and will supplement this with the
relevant correspondence involved in the investigation of the death
and with any matters arising.
To make most use of the PCA evidence base, the
paper will examine as many of the supervised cases involving the
death of a member of the public as can be accessed in a five-year
window, relating to the Home Office categories 1 to 3. The definition
classes police-related deaths as:
Category 1: Fatal road traffic incidents involving
the police
Category 2: Fatal shooting incidents involving
the police
Category 3: Deaths in or following custody
Category 4: Deaths during or following other
types of contact with the police
For the purposes of the current analysis two
groups have been excluded. Category Four deaths in custody and
road traffic incidents involving emergency responses and standard
patrol collisions. The reason for this is that each of these groups
will include deaths among those not involved directly with the
police. As the unit of analysis in the current study is the individual
who has died, it was decided that the primary focus of the study
would be on those who died in police custody, but to use an overview
analysis of pursuits and fatal shootings as both a context and
as contrast groups for the main analysis. In sum, what this means
is that the results are presented as:
1. Summary characteristics of the 302 deaths
considered in the report
2. Comparison of Category 3 custody deaths
with pursuit and shootings deaths from the same period
3. Analysis of Category 3 custody deaths
4. Analysis of ethnicity factors in Category
3 custody deaths
This, in effect, means that the study will consider
fatal road traffic incidents, deaths in police care and custody
and fatal police shootings that have been supervised by the PCA.
The five-year window selected, from April 1998
to March 2003, is an attempt both to maximise the sample and to
ensure that as much of the information that can be accessed within
the PCA is used. There are limitations in data at both ends of
the selection. For the earliest year, 1998-99, a number of the
files have been destroyed and so some of these are likely to be
excluded (in cases where no information can be accessed from other
sources). For the most recent year, 2002-03, the problem is that
many investigations have not been completed by the time of writing,
and so there will be limited information available, and what information
there is, will be of limited reliability as it will not have been
confirmed through all the relevant investigative channels.
The search strategy for identifying files was
by using the PCA Annual Reports and then reconciling these with
information accessed from the PCA computerised database or from
the PCA Press Office files. Once the files had been identified,
the physical tracking down of the case used one of four sequential
mechanisms:
1. Was the file held by the PCA research
department?
2. Was the file available in the storeroom
of completed files within the PCA?
3. Was the file held at the PCA archives
depot?
4. Is the file currently with the member
or caseworker as it is an ongoing case?
A total of 305 files were identified, but three
of these files could not be tracked down, meaning that the total
number of cases entered on the database is 302. For this reason,
the data presented below, on the 302 files accessed, analysed
and entered, is less likely to involve ongoing "live"
cases (most likely from 2002-03) or those held in the archives
(1998-99). Similarly, even among older cases, those that are particularly
complex are more likely to be ongoing and so are less likely to
be complete, for the purposes of the current analysis.
ANALYSIS AND
BASIC RESULTS
The analysis outlined below is based on the
302 cases identified as falling into one of the first three categories,
divided as below:
Fatal police shootings
12 (4%)
Road traffic incidents
137 (45.4%)
Deaths in custody
153 (50.7%)
This is reflected in the year breakdown, shown
in Table 1 below
Table 1
YEARLY BREAKDOWN OF CASES INCLUDED IN THE
STUDY
| 1998-99 | 1999-2000
| 2000-01 | 2001-02
| 2002-03 |
| | |
| |
| 46 (15.2%) | 57 (18.9%) |
57 (18.9%) | 70 (23.2%) | 72 (23.8%)
|
There are two reasons why this cannot be regarded as definitive
trend data in spite of the apparent increase in numbers over the
period of study. First, the availability of information relied
on access to the file (although this was possible in almost all
cases). However, it is also reliant on referral policy (particularly
in road traffic incidents about whether the police involvement
was sufficient to refer) and subsequent PCA decision-making about
the acceptance of referrals. More importantly, the overall data
disguise shifting patterns within the two main classes of death
examined—fatal road traffic incidents and deaths in custody
(as shown in Figure 1 below). Thus, while the total number of
deaths in custody have remained broadly consistent over the course
of the study, the number of fatal road traffic incidents have
increased dramatically in the same period.
Characteristics of those who have died
The mean age of those who died was 34.4 years, although it
should be pointed out that there is a wide range with the youngest
victim two years old (a victim in a road traffic incident) and
the oldest 87 years old. The sample was also predominantly male
(n=271, 89.7%), with only 31 deaths (10.3%) involving female victims.
While all of the victims of police shootings were male, 20 of
the female deaths were in road traffic incidents and 11 were deaths
in police care or custody.
Ethnicity data was available for 271 individuals (90%). Of
these, 218 (80.1%) were classed as white, white British or white
European, with 27 victims classed as black, black British or Afro-Caribbean
(9.9%), 20 (7.4%) as Asian or Indian, and seven as from other
ethnic backgrounds (2.6%).
In terms of vulnerability, 90 of the 293 cases where this
was known (30.6%), involved a victim with a previously identified
mental health problem—in 26 cases this had been diagnosed
by a psychiatrist, in 22 cases by the individual's GP and in 42
cases, mental health problems had been identified elsewhere (eg
by prison doctors or social workers). While up to three separate
diagnoses were recorded for six individuals, a history of self-harm
was indicated in 29 individuals (32.2%), depression in 32 cases
(35.6%), alcohol dependence in 21 cases (23.3%), drug dependence
in 13 cases (14.4%) and schizophrenia or psychotic symptoms in
20 cases (22.2%). A further indication of substance use was derived
from the post mortem toxicology reports, with an average of 1.2
active drugs reported from the toxicology reports. Of the 297
cases for which information was available, 178 individuals (59.9%)
were positive for at least one drug or alcohol.
Alcohol was the substance most frequently identified, present
in 107 cases (35.4% of the total sample). With regard to illicit
drugs, cannabis was identified post mortem in 50 deaths (16.8%),
cocaine in 34 cases (11.4%) and heroin or heroin/morphine in 22
cases (7.4%). The other drugs frequently recorded were benzodiazepines
in 38 cases (12.8%), although it is not clear if this was prescribed
or illicitly diverted drugs and novel stimulants (such as ecstasy
and its analogues) in 24 cases (8.1%).
In terms of the location of the incident, large urban forces
were, as would be expected, highly represented. A total of 48
cases (15.9%) occurred in the Metropolitan Police area, with the
next highest prevalence in Greater Manchester (n=21, 7%), followed
by West Yorkshire (n=17, 5.6%) then both Devon and Cornwall and
Thames Valley (n=14, 4.6%). However, each of the 43 Home Office
forces has experienced at least one death in the five-year time
window (a full breakdown is presented in Appendix 1).
Although difficult to classify, the reason the individual
was initially in contact with the police was as a result of police
intelligence in 166 cases (55.7%) or as a result of driving matters
(89 cases, 29.9%). Other reasons for initial police involvement
were being observed committing a crime (in 14 or 4.7% of cases),
routine stops (in 11 or 3.7% of cases) or because the individual
was reported to have been "behaving suspiciously" (in
13 or 4.4% of cases).
Data were also gathered on the location of death although
this can be misleading as it will often reflect where death was
pronounced to be extinct rather than where the individual died.
For this reason, the most common location was in hospital (in
130 cases, 43.5%), followed by in a public place (106 cases, 35.5%).
Only 51 of the 298 cases on which this data was available (17.1%)
actually died in police cells or other parts of the police station.
A further 12 (4%) died at home.
At the time of the incident, 124 of the 298 of the individuals
for which the information was available (41.4%) were either detained
or under arrest. In the remainder of cases, the police were attempting
to arrest the individual (91 cases, 30.4%), there was no arrest
intention (69 cases, 23.1%) or the death occurred after the individual
had been released from police custody or contact (15 cases, 5%).
Causes of death and issues of concern for the police
In 24 cases (8.1% of the 298 cases for which information
was available) there was a restraint concern that was subject
to investigation (although this concern was not necessarily upheld
by the investigators), ten of these involving the use (and alleged
misuse) of handcuffs. These include two cases where the individual
was still in handcuffs when taken to hospital, one case where
an individual was handcuffed while unconscious, and one occasion
where the individual had flexi-cuffs used to restrain his or her
legs. In four cases, the restraint issue relates to the use of
CS spray, in one case to the type of restraining hold used by
the police officer and in two cases to the length of time the
individual was left sitting restrained in a police van. However,
in a number of other incidents the matter investigated related
to the technique used by officers to control the individual—including
the use of a "bear hug" in one incident, forcing a man's
arm up behind his back in another and the violent struggle preceding
arrest in a third case.
Similar problems exist in making sense of the cause of death
identified at the post mortem, not least because in 13 cases,
three causes of death are given while in a further 40 cases, two
causes of death are provided by the pathologist. However, among
the 301 cases for which at least one cause of death was available
from the post mortem investigation, the most common main cause
of death was "multiple injuries" in 76 cases (25.2%),
followed by alcohol or drug toxicity in 47 cases (15.6%) and "head
injury" in 33 cases (10.9%). Cause of death in all 12 fatal
shooting cases was given as the effects of the shot or shots.
In 10 cases (3.3%), "hanging" was given as the
cause of death, with ligature strangulation given as the cause
of death in one additional case. In four cases, excited delirium
is given as the cause of death and, in five cases, asphyxiation
is given as the cause of death. However, there are a total of
73 primary causes of death cited in cases included in the study.
Complaints, criminal and disciplinary outcomes
In only 16 of 300 cases (5.3%) was there a formal complaint
made by family members as a result of the incident that led to
the death—10 of these arising in custody deaths, five relating
to road traffic incidents and one following a police shooting.
However, in several of these cases, more than one issue was raised
in the course of the complaint (see Table 2 below). Furthermore,
there are concerns expressed by family members that are recorded
in the investigation file in a number of cases, while there may
yet be complaints from family members in some of the cases that
have not yet been completed.
Table 2
COMPLAINTS ARISING FROM DEATHS INVOLVING THE POLICE
| Category | Nature of complaint
|
| Pursuit | Officers knew the occupants and therefore should not have pursued; There was a delay in notifying the family about the incident; Witnesses stated that an officer kicked the deceased.
|
| Pursuit | Passenger in pursued car complained that he was assaulted by an officer.
|
| Pursuit | Pursuing officer committed traffic offences in the pursuit; The pursuit was dangerous and should not have taken place; The FLO lied to the family; The officer was unsympathetic.
|
| Pursuit | Relating to the actions of the police prior to the collision, at the scene, at the hospital and with regard to family liaison.
|
| Pursuit | Should not have been pursued; conduct of the pursuit.
|
| Death in custody | Obvious ligature point in the cell.
|
| Death in custody | Unlawful arrest; unnecessary force used.
|
| Death in custody | Officer failed to look after the individual's health and welfare; officer should have acted quicker; officer's actions contributed to the death; officer was aggressive and assaulted victim's mother.
|
| Death in custody | Failed to provide proper medical attention; Custody officer listed victim as unknown when he was known to the police.
|
| Death in custody | Breach of Code C: failure in duty.
|
| Death in custody | Unlawful detention: officers acting outside the powers of the Mental Health Act; excessive use of force.
|
| Death in custody | Deceased not allowed to use toilet nor to change clothes; FME pronounced the deceased fit to detain; Delay in informing family; FLO attitude not acceptable.
|
| Death in custody | Failure of officers to make inquiries about drugs and alcohol consumption; Failure to update custody records; Failure to observe detainee properly.
|
| Death in custody | Inadequate investigation; Dishonesty of police officers; Failure of officers to intervene.
|
| Death in custody | The actions of officers caused the deceased to lapse into unconsciousness due to the failure to monitor prisoners.
|
| Shooting | Initial complaint of unlawful use of force and falsified accounts. Subsequent complaint alleged that: Family not informed soon enough about the death; FLO had no respect for family privacy; Offer to pay for funeral was made and withdrawn; Scene of shooting was managed insensitively.
|
| |
The final report records concerns expressed by family members
or community groups in a further 12 cases where no formal complaint
was made. These included:
— Concerns that the deceased should have been taken
to hospital earlier.
— Concern that the time for arrest given by the
police was inaccurate.
— Concern that the FME was not called, while the
officers were watching football and that the officers did not
do all they could to preserve safety.
— Concerns about the level of care and why the individual
was not taken to hospital.
— Concerns about delays in informing the family
and that clothing was seized.
— Dissatisfaction with the IO who was seen as rude
by the family.
— Family concern that police actions contributed
to the death.
— Concerns that the deceased was beaten and that
potential witnesses were not requested.
In only three of the finalised cases did officers face criminal
charges for involvement in a death, and, on each occasion, was
subsequently acquitted (although a further 31 cases have not yet
reached this stage). These were:
(a) Five officers were acquitted of misfeasance and manslaughter
following a death in a custody suite in Humberside.
(b) One officer was acquitted of misfeasance following
a cell death in Lancashire.
(c) A police driver was found not guilty of dangerous
driving following a police pursuit.
In one further case, an officer was required to resign at
a disciplinary hearing. In no finalised case were any officers
demoted in rank following disciplinary proceedings.
In terms of formal disciplinary proceedings, 16 of 260 cases
(6.2%) resulted in officers receiving formal disciplinary outcomes.
In eight cases an officer was admonished, in six cases this happened
to two officers, and in one case each, three and four officers
respectively were admonished or received a warning following investigations
into police-related deaths. A total of 168 officers received advice
from a senior officer in a total of 65 cases (of 260 that had
reached disciplinary conclusions by the time of writing). In one
case, a total of 15 officers were given advice following the investigation.
At the time of analysis, information regarding recommendations
was only available in 259 cases. Of these 259, policy, training
or organisational recommendations were made in only 96 cases.
The number of recommendations made in each case ranged between
one and 30. In the remaining 163 cases (62.9%) no recommendations
of any sort were made. Where recommendations had been made, information
about implementation would not always be provided to the PCA,
as the Authority has no role in monitoring the implementation
of such recommendations.
Finally, at the time of writing, an inquest had been held
in 194 cases. In a further 56 cases the inquest date was yet to
be set. In 45 cases no inquest was scheduled to take place, generally
involving road traffic incidents where those driving the cars
that killed the victims were later convicted of causing the death.
Of the inquests held, 73 returned a verdict of "accidental
death" (37.8%), with the jury in one further case returning
a verdict of "accidental death contributed to by neglect".
A further 26 cases (13.5%) resulted in verdicts of "misadventure"
and 28 cases (14.5%) in verdicts of "natural causes".
In 15 cases, an "open" verdict was returned, and in
five cases the verdict was "lawful killing" (these were
all police shootings). In a further six cases, the verdict was
"drug-related death".
Twelve cases (6%) resulted in "unlawful killing"
verdicts (although all but one of these involved police pursuits
and related to instances where the pursued driver had killed another
road user or pedestrian). In only one custody case, relating to
the death of a black man in Humberside, did a custody death result
in a verdict of unlawful killing.
Ten deaths resulted in verdicts of suicide and two in verdicts
of "suicide contributed to by neglect". One of the 10
suicide deaths was a police shooting described by the coroner
as a "suicide by cop" incident.
Comparison of death categories
There was a significant disparity in age profiles with the
mean age of deaths in custody (mean = 40.5 years) markedly higher
than fatal shootings (mean = 33.7 years), which in turn was significantly
higher than road traffic incidents (mean = 27.2 years; F = 28.1,
p>0.001). The largest proportion of female deaths was in road
traffic incidents (14.6%) compared with none of the 12 shootings
and 7.2% of deaths in custody, which constitutes 11 cases (x2=5.73,
p=0.06, ns).
In terms of shifting patterns of deaths over the period of
investigation, the basic trends are shown in Table 3 below:
Table 3
BREAKDOWN OF CASES BY YEAR FOR EACH OF THE DEATH CATEGORIES
| Year | Shootings (n=11)
| RTI (n=117) | DIC (n=122)
|
| 1998-99 | 0 | 13 (9.5%)
| 33 (21.6%) |
| 1999-2000 | 3 (25.0%) | 24 (17.5%)
| 30 (19.6%) |
| 2000-01 | 2 (16.7%) | 26 (19.0%)
| 29 (19.0%) |
| 2001-02 | 4 (33.3%) | 36 (26.3%)
| 30 (19.6%) |
| 2002-03 | 3 (25.0%) | 38 (27.7%)
| 31 (20.3%) |
| | |
|
When ethnicity is compared by category of death, there is
no significant difference. To enable this analysis, ethnicity
categories were collapsed into four groups—white, Asian,
black and other. For all three categories of death, over 75% of
those who died were white. Of the 27 deaths classed as among black
people, two (17.4%) were police shootings, 13 were in fatal road
traffic incidents (48.1%) and 12 were deaths in custody (42.3%).
Of the 20 individuals classed as Asian who died, 11 (55%) died
in road traffic incidents and nine (45%) in deaths in custody.
Those involved in road traffic incidents were less likely
to come from identified vulnerable populations. With regard to
a confirmed mental health indicator, this was the case for 9/12
(75%) of those fatally shot by the police, and 50% (n=75) who
died in police custody, compared with only 4.5% of those whose
status was known in road traffic incidents (x2 = 81.7, p<0.001).
Similarly, while victims of fatal road traffic incidents averaged
0.7 different active drugs in their bloodstream at post mortem,
the average for fatal shooting victims was 1.2 (in each case this
included alcohol) and in deaths in custody the average was 1.6
(F = 16.6, p<0.001).
There were significant differences in the disciplinary outcomes
as a consequence of the category of incident (see Table 4)
Table 4
DISCIPLINARY OUTCOMES BY CLASS OF INCIDENTS
| Shooting (n=11) |
RTI (n=117) | DIC (n=122)
| F, sig |
| No of officers disciplined | 0.14
| 0.01 | 0.20 | 5.61, p <0.01
|
| No of officers given advice | 1.57
| 0.18 | 1.06 | 11.61, p<0.001
|
| No of policy recommendations | 4.6
| 0.4 | 1.3 | 13.46, p<0.001
|
| | |
| |
As is evident from the above table, road traffic incidents
were markedly less likely than either of the other classes of
police-related deaths to result in disciplinary outcomes or in
recommendations of policy change by the SIO (which were most common
in cases of police shootings). However, it is notable that the
highest levels of both main disciplinary outcomes occurred in
death in custody cases.
Focusing only on deaths in custody
This section of the analysis will focus on the 153 cases
of Category Three death according to the Home Office classification
scheme. To re-iterate the main characteristics of the group, their
mean age was 40.5 years (with a range of 15 to 76 years), and
they were predominantly male (142/153 or 92.8%). A total of 27
individuals (17.6%) were categorised as non-white in the sample—nine
as Asian, 12 as black and six as from other ethnic backgrounds.
However, ethnicity data were missing on 11 cases (generally among
files from the earlier years where the file was no longer available).
On average, post mortem analysis revealed that they had consumed
a mean of 1.6 active substances[64]
in the period prior to their death—most commonly alcohol,
which was detected in 67 cases (43.8% of cases). Other drugs consumed
are shown in Table 5 below:
Table 5
MAIN SUBSTANCES DETECTED POST MORTEM AMONG DEATH IN CUSTODY
CASES
| Substance | Number of cases
| % |
| Cocaine | 27 | 17.6
|
| Heroin | 19 | 12.4
|
| Benzodiazepines | 31 | 20.3
|
| Ecstasy | 13 | 8.5
|
| Cannabis | 21 | 13.7
|
| | |
It is important to note that benzodiazepines will include
those prescribed therapeutically—in some cases in custody—and
so are not, unlike the other substances included, necessarily
indicative of drug abuse.
The group was rendered further vulnerable by the prevalence
of mental health problems identified. Just over half of the cases
for which information was available (75/149, 50.3%) had a prior
indication of mental health problems—with 17 individuals
having a previous diagnosis by a psychiatrist, 20 having GP indications
of mental health problems and with the remaining 38 having other
indications in the investigation files of earlier mental health
problems. This is a level of mental health problems considerably
in excess of that generally reported in custody populations (Bennett,
1998; Ingram and Johnson, 1998).
For 30 individuals (19.6% of all custody deaths included)
there were prior indications of anxiety or depression, 26 had
recorded histories of self-harm (17%), 17 had markers for psychosis
or schizophrenia (11.1%), 12 had histories of drug dependence
(7.8%) and 18 (11.8%) had histories of alcohol dependence. "Behaviour
problems" or other psychiatric problems were recorded in
six further individuals. In other words, for a substantial proportion
of the custody death group considered in this report, there were
not only indications of mental health problems and/or substance
abuse, but there were previous contacts with health agencies attempting
to address these problems.
Locations of the death
Again, the police service most commonly associated with custody
deaths was the Metropolitan Police Service (MPS) accounting for
32 (20.9%) cases. The force with the next highest level of custody
deaths was Northumbria (n=10), followed by West Midlands and Devon
and Cornwall (eight deaths each). However, the 153 deaths were
spread between 36 different police forces in England and Wales.
In more specific terms, the place of death was recorded as
the police station or cell in 45 cases and "police vehicle"
in a further six cases—in other words 33.8% of the 151 cases
for which this information was available involved death in a police
location. The other main locations for death recording were in
hospital (79 cases or 52.3% of the valid sample), with 12 individuals
dying in a public place and nine at home.
The initial contact resulted from "police intelligence"
in the vast majority of cases (111 or 74.5% of the death in custody
cases). Less frequent reasons for the initial police involvement
were traffic or driving matters (in 13 cases), the individual
being observed committing a crime (12 cases), the police perception
that the individual was engaging in suspicious behaviour (seven
cases) or routine stops (four cases). Other reasons were given
in a further two cases and this information was not available
in four cases. As has been detailed above for all deaths, there
were restraint-related aspects of the investigation in 23 cases
(15.4%)—generally relating to the timing and location of
handcuffing, the use of force in the initial arrest attempt, the
use of CS spray or delays in the removal of restraints when it
was apparent that the individual was experiencing significant
health problems.
Although custody detention issues are likely to be significant,
the attempt to quantify this is problematic. The calculated mean
time is 384 minutes (just over six hours), but this is heavily
skewed by two cases where the individual is in custody for more
than two days. However, it is worth noting that in nine cases,
the individual is in detention for 24 hours or more.
The prevalence of substance use is clearly indicated by the
fact that "toxicity" is cited as a cause of death in
47 cases (31.8% of the 148 cases for which this information is
available). Head injuries are cited in 12 cases, hanging in 10
cases, multiple injuries in seven, hypoxia in five cases and excited
delirium in four cases. In at least seven further cases, alcohol-related
factors are cited among the causes of death. Changes over time
in the frequency of both toxicity deaths and hanging deaths are
given in Figure 2 below:
As can be seen from the above table, there is no consistent
pattern in deaths where toxicity is given as a cause, but there
appears to be a positive change in the number of strangulation
or cell deaths with only one death in each category in each of
the last two years.
Investigations and outcomes
In only two of the 131 cases that have reached that stage
was there a criminal trial of an officer, with six officers tried
in total, with all six being acquitted. An officer was required
to resign following one of the custody deaths, and in 14 cases
a total of 25 officers were warned or admonished following the
investigation. In 45 of the 127 cases (35.4%) completed to date,
officers were given advice by a senior officer, resulting in a
total of 134 officers dealt with in this way.
In 49 of these 127 cases (38.6%), the Senior Investigating
Officer (SIO) recommended further action at a policy level. The
most common areas identified by senior investigators as needing
to be addressed were:
— Training needs for officers (n=39, 30.7%).
— Issues around the management of vulnerable populations
(n=31, 24.4%).
— Equipment issues (n=30, 23.6%).
— Incident management issues (n=21, 16.5%).
The other most common themes identified by SIOs were custody
management issues (in nine cases), failures of inter-agency working
(in seven cases) and failures of post-incident investigation (in
five cases).
A further investigation was carried out in the form of a
coroner's inquest in 112 cases. Details of the inquest outcomes
are given in Table 6 below. It should be noted that multiple verdicts
are given in a number of cases:
Table 6
INQUEST VERDICTS GIVEN IN DEATH IN CUSTODY CASES IN CASES
COMPLETED TO DATE
| Inquest verdict | Frequency
| % |
| Accidental death | 29 | 19.1
|
| Misadventure | 15 | 9.9
|
| Open | 13 | 8.6
|
| Drug related | 6 | 3.9
|
| Suicide | 10 | 6.6
|
| Accidental death contributed to by neglect |
1 | 0.7 |
| Natural causes | 28 | 18.4
|
| Suicide by neglect | 2 |
1.3 |
Accidental death contributed to by restraint and failure
to provide medical care
| 1 | 0.7 |
| Misadventure contributed to by police neglect
| 1 | 0.7 |
| Pending | 38 | 25.0
|
| Unknown | 2 | 1.3
|
| Total | 147 | 96.7
|
| | |
For the 10 complaints received to date (details of which
are provided above), four are still under active investigation.
In the remaining cases, one has been informally resolved, two
have been upheld in part and three have not been upheld.
Examining ethnicity issues among custody deaths
This part of the analysis will focus on the 27 non-white
individuals who died in custody in the period of the review. The
mean age of the non-white group was 37.3 years (range of 19-66
years) and consisted of 26 males and one female.
Seven of these individuals (26.9%) had a previous indication
of mental health problem(s)—three on the basis of psychiatrist
diagnosis and four based on information from other sources in
the SIO's report (information was missing in one case). Four of
these individuals had drug dependence indicators and one had an
alcohol dependence marker. Two individuals had indications of
schizophrenia, two had markers for either anxiety or depression,
and one had another psychiatric problem. In other words, there
were a total of 10 symptoms indicated in this group.
In 22 of the 26 cases where this information was available
(84%), there was at least one active substance present at the
toxicology. As with the larger sample, the most common substance
present was alcohol (48%), followed by cocaine (28%), heroin or
morphine (20%), cannabis (20%) and benzodiazepines (16%). There
was no relationship between mental health status and the likelihood
of substance use prior to death.
More than half of the cases (n=14, 53.8%) of custody deaths
involving ethnic minority individuals occurred within the MPS,
with a further four deaths occurring in West Midlands, two in
Sussex, and one each in Northumbria, Essex, West Yorkshire, Hampshire,
Surrey and Hertfordshire.
For the ethnic minority group, just over half the deaths
occurred in hospital (13/25, 52%) with four occurring in police
stations or cells and one in a police vehicle. Three individuals
died at home and four in a public place. In the majority of cases
(17/25), the reason for the initial police contact was based on
police intelligence, and also for the majority (18/26) the individual
was under arrest at the time of the death. However, for a further
five, death occurred post release, and for the final three individuals
death occurred either while the police were in the process of
attempting to arrest or detain the person.
In five of the 23 cases for which this information was available,
there was a restraint issue, four relating to the method of restraint
(generally about the use of handcuffs) and one involving a violent
struggle prior to the arrest.
However, in 11 cases (42.3%) toxicity was cited as a cause
of death, with multiple injuries cited in three cases, and excited
delirium and head injury in two cases each. The full range of
primary causes of death are given in Table 7.
Table 7
PRIMARY REPORTED CAUSE OF DEATH IN CUSTODY DEATHS AMONG
NON-WHITE DEATHS
| Post mortem cause of death
| | | |
| Year | First |
Second | Third |
Inquest verdict |
| 1998-99 | Toxicity |
| | Unknown |
| Advanced alcoholic liver disease
| | | Natural causes
|
| Multiple injuries |
| | Accidental death |
| | Hypothermia |
| | Misadventure |
| Toxicity |
| | Accidental death |
| Dilated cardiomyopathy |
| | Natural causes
|
| Toxicity |
| | Misadventure |
| Bronchopneumonia | Inhalation of vomit
| Toxicity | Accidental death
|
| Excited delirium |
| | Pending |
| Not known |
| | Unlawful killing |
| 1999-2000 | Toxicity |
| | Accidental death |
| Irreversible cerebral anoxia
| Toxicity | | Misadventure
|
| Ischaemic heart disease |
Coronary heart disease | Toxicity
| Natural causes |
| Head injury |
| | Accidental death |
| Hepatitis | Multi organ failure
| | Open |
| Head injury |
| | Accidental death |
| Excited delirium | Toxicity
| | Drug related |
| Asphyxiation |
| | Misadventure |
| 2000-01 | Toxicity |
| | Accidental death |
| Unknown |
| | Open |
| 2001-02 | Toxicity |
| | Misadventure |
| 2002-03 | Multiple injuries
| | | Pending
|
| Chronic bronchitis | Emphysema
| | Pending |
| Cardiac arrest |
| | Pending |
| Respiratory distress syndrome
| Toxicity | | Pending
|
| Tracheobronchitis | Skull fracture
| | Pending |
| Multiple injuries |
| | Accidental death |
| | |
| |
In outcome terms, there has been one trial in the 22 completed
cases, with 21 inquests having taken place. The details of inquest
verdicts are given in Table 8 below:
Table 8
INQUEST VERDICTS IN DEATHS IN CUSTODY INVOLVING INDIVIDUALS
FROM BME GROUPS
| Inquest verdict | Frequency
| % |
| Accidental death | 8 | 29.6
|
| Misadventure | 5 | 18.5
|
| Open | 2 | 7.4
|
| Drug related | 1 | 3.7
|
| Pending | 6 | 22.2
|
| Unknown | 1 | 3.7
|
| Natural causes | 3 | 11.1
|
| Unlawful killing | 1 | 3.7
|
| | |
In four of the 22 cases completed to date, a total of eight
officers were warned or admonished and a further 21 officers were
given advice by senior officers.
When inferential statistical comparisons were carried out
comparing white and non-white custody deaths, almost no statistical
differences emerged. Although white custody deaths were typically
older (40.7 years versus 37.3 years) this was not significant.
A significantly lower proportion of non-white deaths in custody
involved mental health problems (28% versus 55.4%; c2 = 6.12,
p<0.05).
There has also been a significant reduction in the proportion
of non-white deaths over time within the window of investigation
in the study, which does achieve statistical significance.
As can be seen from the figure above, the number of deaths
among non-white individuals decreased over the first four years
of investigation but has increased in the most recent year, while
the total number of white deaths has remained relatively constant
over the period of investigation.
Finally although it did not attain statistical significance
and the numbers are relatively low, it is notable that there are
restraint issues in a higher proportion of the deaths involving
non-white individuals (21.7%) than among white individuals (12.3%)
(see Appendix 2).
In terms of investigation outcomes, a slightly higher mean
number of officers received warnings or admonishments in non-white
deaths (mean = 0.36) than in white deaths (mean = 0.18) but this
was not significant. Conversely, more officers received advice
on average for white custody deaths (mean = 1.2) than in non-white
custody deaths (mean = 0.9) but this also failed to attain significance.
OVERVIEW
The study shows a relatively consistent pattern of custody
deaths in the five-year window examined, with the 153 PCA-supervised
custody deaths roughly equally spread across the period of investigation.
This contrasts with the comparison group of pursuit deaths where
the trend is upwards over the period of assessment, with the exception
of the most recent year. Although exceptionally low as a proportion
of arrests (153 deaths from around 6-7 million arrests in the
period of investigation), it would not indicate that recent developments
in monitoring or training are having a resulting effect on the
overall number of fatalities. However, it is important to note
that, over the last 10 years, the trend has been towards reduced
numbers of deaths, particularly from hangings, the cause of death
that is most obviously preventable. However, similar improvements
have not been detected in the prevention of alcohol and drug-related
deaths.
Within this custody group, there are marked variations in
the demographic characteristics of those who have died. The group
are primarily male, more than 80% are of white ethnic origin,
and with a mean age of around 40 years (although there are a broad
range of ages). There is an over-representation of ethnic minority
individuals in custody deaths in the five-year window studied—while
17.6% of deaths are of individuals classed as non-white, the 2001
census for England and Wales reported that 9% of the population
are from BME groups. It is also slightly higher than the arrested
population reported by the Home Office for 2001-02, which showed
that 13% of the total arrested population were from minority groups.
While this may partly relate to the way ethnicity has been classified
in some cases (and inconsistencies across measures), the over-representation
of ethnic minority groups among the deceased group should not
be ignored.
One of the main findings of the study is the exceptionally
high prevalence of mental health problems recorded in the police
investigation reports, at around 50% although higher among white
deaths than among ethnic minority groups. In contrast, deaths
among minority detainees were slightly more likely to result in
the investigation considering aspects of the restraint of the
detainee. However, there are very few clear, statistically identifiable
group differences in the characteristics of the incident or the
individual as a function of ethnicity, although the small numbers
of individuals from BME groups means that statistically robust
differences are difficult to detect.
The general issue of vulnerability cannot be overstated.
The preponderance of alcohol consumption and illicit drug use
(particularly relating to the use of both cocaine and benzodiazepines)
is a risk in its own right and compounds the risk associated with
mental health problems. The latter, referred to as dual diagnosis
(Strathdee et al, 2003), is associated with markedly increased
risk of mortality from both custody deaths and from police use
of firearms.
One of the most contentious issues will be the apparently
low levels of culpability for police officers resulting from the
total of 300 cases. Although seven officers were charged with
criminal offences, none were convicted. One officer was required
to resign and none were demoted. Similarly, in only one case,
did an inquest verdict of "unlawful killing" relate
to police activity (in the same case that five officers were charged
and subsequently acquitted of criminal offences). However, in
many of these cases, none of the adjudicating bodies—the
inquest, the Crown Prosecution Service, the police investigators
or the PCA supervising members—have found fault with police
conduct and many of the disciplinary outcomes relate to ancillary
matters rather than the actual cause of death.
Before drawing tentative conclusions, it is important to
acknowledge the limitations of the study. All of the analyses
are based on summaries of the PCA file, which in turn is heavily
reliant on the final police report into each incident. These reports
not only vary in depth and quality, they are also designed for
a purpose other than research and so may not be consistent with
the aims of the project.
However, there are a number of key inferences that can be
derived. Although there have been significant gains, it is essential
that the police remain vigilant and seek to eliminate the preventable
deaths that do, on occasion, still occur. However, deaths are
not randomly distributed across the population or indeed the arrest
population, and this is mediated by incident and response type.
Vulnerable populations (those with a mental illness and/or users
of alcohol or illicit drugs are hugely over-represented), while
those from ethnic minorities are less likely to have a recorded
mental health problem but are likely to be slightly younger and
slightly more likely to have been involved in an incident that
provoked concerns about the method of restraints.
There are a number of implications of this for training and
supervision. Earlier access to medical interventions are essential
as is first aid training and refresher courses for all officers
involved in custody. Similarly, officers must be made aware of
the risk factors for self-harm and mental health problems, and
for ensuring that a "safety first" approach is adopted
in custody suites. It may appear that, following the significant
gains in the late 1990s, some forces may have allowed complacency
to creep in thus generating risks for those held in custody.
All deaths in custody are, at one level, preventable, although
in practice, this is obviously not achievable as many "natural
causes" deaths may be completely unrelated to any actions
on the part of the police. The repetition of areas of recommendations
from final reports suggests that prevention is not yet a sufficient
objective and that some opportunities for organisational learning
are not being taken. To ensure that HRA requirements are adhered
to, the police service must ensure that lessons are learned and
that deaths, particularly those involving vulnerable groups, are
minimised.
All analyses are also made more problematic by the huge variations
in the causes of death identified at post mortem, and this is
reflected in the inquest verdicts passed down. In only one cases
was the inquest verdict "unlawful killing" in relation
to actions of the police and, given this finding, it is perhaps
not surprising that only one officer was charged with a criminal
offence. The most common disciplinary outcome (in cases where
this arose was either formal admonishment or advice for officers),
and the recommendation of organisational issues varied markedly
from case to case, although much more common in shootings cases
than in deaths in custody or even more markedly when compared
to road traffic incidents.
APPENDIX 1
POLICE FORCE LOCATION (ALL DEATHS)
| | |
| |
| Frequency | %
| Valid Percent
| Cumulative
%
|
| | |
| |
| Cleveland | 3 | 1.0
| 1.0 | 1.0 |
| Devon & Cornwall | 14 |
4.7 | 4.7 | 5.6
|
| Northumbria | 12 | 4.0
| 4.0 | 9.6 |
| Metropolitan Police | 48 |
15.9 | 15.9 | 25.6
|
| Essex | 7 | 2.3
| 2.3 | 27.9 |
| Leicestershire | 3 | 1.0
| 1.0 | 28.9 |
| South Yorkshire | 5 | 1.7
| 1.7 | 30.6 |
| Merseyside | 13 | 4.3
| 4.3 | 34.9 |
| Greater Manchester | 21 |
7.0 | 7.0 | 41.9
|
| Durham | 3 | 1.0
| 1.0 | 42.9 |
| South Wales | 11 | 3.7
| 3.7 | 46.5 |
| Lincolnshire | 5 | 1.7
| 1.7 | 48.2 |
| Sussex | 8 | 2.7
| 2.7 | 50.8 |
| West Midlands | 12 | 4.0
| 4.0 | 54.8 |
| West Yorkshire | 17 | 5.6
| 5.6 | 60.5 |
| Avon & Somerset | 7 |
2.3 | 2.3 | 62.8
|
| Dorset | 4 | 1.3
| 1.3 | 64.1 |
| Gloucestershire | 3 | 1.0
| 1.0 | 65.1 |
| Hampshire | 7 | 2.3
| 2.3 | 67.4 |
| City of London | 1 | .3
| .3 | 67.8 |
| Derbyshire | 3 | 1.0
| 1.0 | 68.8 |
| Gwent | 2 | .7
| .7 | 69.4 |
| Surrey | 7 | 2.3
| 2.3 | 71.8 |
| Kent | 1 | .3
| .3 | 72.1 |
| Bedfordshire | 3 | 1.0
| 1.0 | 73.1 |
| Nottinghamshire | 3 | 1.0
| 1.0 | 74.1 |
| Thames Valley | 14 | 4.7
| 4.7 | 78.7 |
| North Wales | 5 | 1.7
| 1.7 | 80.4 |
| West Mercia | 4 | 1.3
| 1.3 | 81.7 |
| Staffordshire | 7 | 2.3
| 2.3 | 84.1 |
| Wiltshire | 1 | .3
| .3 | 84.4 |
| Norfolk | 4 | 1.3
| 1.3 | 85.7 |
| North Yorkshire | 4 | 1.3
| 1.3 | 87.0 |
| Cheshire | 3 | 1.0
| 1.0 | 88.0 |
| Humberside | 4 | 1.3
| 1.3 | 89.4 |
| Hertfordshire | 1 | .3
| .3 | 89.7 |
| Cambridge | 2 | .7
| .7 | 90.4 |
| Lancashire | 9 | 3.0
| 3.0 | 93.4 |
| South Yorkshire | 3 | 1.0
| 1.0 | 94.4 |
| Dyfed Powys | 5 | 1.7
| 1.7 | 96.0 |
| Cumbria | 3 | 1.0
| 1.0 | 97.0 |
| Warwickshire | 3 | 1.0
| 1.0 | 98.0 |
| Northamptonshire | 3 | 1.0
| 1.0 | 99.0 |
| Suffolk | 2 | .7
| .7 | 99.7 |
| British Transport | 1 | .3
| .3 | 100.0 |
| Total | 301 | 100.0
| 100.0 | |
| | |
| |
| | |
| |
APPENDIX 2
ETHNICITY, RESTRAINT ISSUES, CAUSE OF DEATH AND INQUEST
VERDICT IN CUSTODY DEATH CASES WHERE RESTRAINT WAS PERCEIVED TO
BE AN ISSUE
| Ethnicity | What was the restraint issue
| Cause of death | Coroners verdict
|
| 1998-99 | |
| | |
| white | Use of CS on person with MH problem
| Organ failure | Suicide |
| white | Held around the chest in reverse bear hug.
| Brain injuries | Accidental contributed by restraint and failure to provide
|
| black | Complaint about handcuffing
| Excited delirium | pending
|
| black | dragged from van—then left on ground with handcuffs on
| Multiple Injuries | unlawful killing
|
| 1999-2000 | |
| | |
| black | handcuff marks, but pathologist could not comment on role restraint played in death
| Toxicity | accidental death
|
| white |
| Excited delirium | accidental death
|
| white | deceased had spent over half an hour sitting handcuffed in the van outside the custody suite
| Aspiration of stomach contents | misadventure
|
| white | use of CS
| Toxicity | misadventure |
| white | was handcuffed during hospital transfer
| Hypoxia | Accidental death
|
| 2000-01 | |
| | |
| asian | officers use of flexi-cuffs to restrain legs in contravention of force police
| Toxicity | accidental death
|
| | deceased was conveyed to hospital still cuffed
| Myocardical infarction | pending
|
| | restrained for hospital transfer
| Multiple Injuries | |
| other | violent struggle prior to arrest
| Unknown | open |
| white | handcuffed white unconscious
| Toxicity | unknown |
| 2001-02 | |
| | |
| white | restrained at hospital due to fear of assault on staff—handcuffs not suitable for long term use
| Acute alcohol withdrawal with ketosis |
|
| white | police took hold of man's arm, put it up his back and forced him to the ground
| Ischaemic heart disease | pending
|
| 2002-03 | |
| | |
| black |
| Cardiac arrest | pending |
| white | police assaulted him during arrest but no evidence to link to stroke
| Bronchopneumonia | pending
|
| white |
| Excited delirium | pending
|
| white |
| Cardio-respiratory failure | pending
|
| white |
| Unknown | pending |
| . | | blood in cell. no explanation as yet
| Inconclusive | pending |
| white | struggled to put on handcuffs and CS used twice
| Inconclusive | pending |
| | |
| |
64
Active substances refers to illicit drugs, alcohol or prescribed
medications (including those diverted through illicit routes). Back
| 
