Joint Committee On Human Rights Third Report

1  Introduction

Our approach

1. When the state takes away the liberty of an individual and places him or her in custody, it assumes full responsibility for protecting that person's human rights—the most fundamental of which is the right to life. This right, and other human rights which protect people detained by the State, now form part of our law under the Human Rights Act 1998. Yet at a time when we have finally abolished the death penalty in the United Kingdom and few of our prisoners serve whole-life sentences, too many still die in custody. Some of these die, of course, from natural causes. A few are killed by fellow inmates. Others die as a result of actions of officers of the state, often without charges being brought or an effective remedy being made available to family and friends. Most deaths are 'self-inflicted', with yet more people in custody, especially women, inflicting upon themselves life-threatening injuries, but surviving.

2. Each and every death in state custody is a death too many, regardless of the circumstances of the person who dies. But we must recognize the harsh reality that many of those who die in state custody have been convicted of no criminal offence and are held only on remand, either in prison or in police custody, or are detained under the Mental Health Act.

3. As this report shows the majority of people entering custody are extremely vulnerable individuals. Many of those who die in custody are young. Most of those who die are vulnerable or sick, with histories of mental illness and drug and alcohol problems. It must be recognised that by taking people into custody the state takes upon itself a particular duty of care, because of their vulnerability, and a special responsibility to ensure their protection and to uphold their human rights.

4. We have undertaken this inquiry in order to discover some of the reasons that lie behind deaths in custody and to propose what might be done to reduce them. We approach the issue of deaths in custody through looking at the right to life and other rights protected in the Human Rights Act and seeking to expand on what they mean. In order to do this it is necessary to go beyond the abstract legal texts and shed light on what practical implications they have for our custodial institutions and authorities which run them. A marked improvement in preventing deaths in custody will not come about by a defensive approach which seeks to only protect the rights but by a much more proactive approach which seeks positively to promote and to ensure the human rights of people in custody. By doing this we can take the Human Rights Act out of a purely legalistic context and make it relevant to the daily practice of people who work for and run our custodial institutions. This positive approach can only have benefits for the working practices of our custodial institutions and the health and well-being of those in custody.

5. This inquiry has considered issues relating to deaths in all forms of state detention, including deaths in prison, police custody, immigration detention and Mental Health Act detention. We have not considered issues relating to other deaths following contact with the police or other state agents, such as deaths following police pursuit, or police shootings.

6. We have taken oral evidence from numerous witnesses with expertise and experience in the causes, prevention and investigation of deaths in custody. We have also received substantial written evidence and visited several institutions of detention. Some of our discoveries during the course of this inquiry have shocked us. At times we have been exposed to the frustration of staff whose attempts to address detainees' human rights are thwarted by an under-resourced and ramshackle physical and administrative environment. We also held a private meeting with members of the families of people who had died in custody. They provided us with compelling evidence of failings throughout our systems of detention, and of the grievous personal consequences of those failings. The family members with whom we met, primarily parents whose sons and daughters had died, told us of their belief that the state had failed them in its duty of care. State institutions had taken into custody people who, in many cases, were depressed, ill, or troubled, and were known by their families to be in need of particular care. Although these vulnerabilities were in most cases also well known to the detaining institutions, or should have been, they had failed in their responsibility to protect the people in their charge from harm. In some cases, there had been failures to provide essential healthcare, support or counselling. In other cases, a family member had died violently, following the use of control and restraint. The families' distress and concern was compounded by uncertainty and secrecy surrounding the circumstances of these deaths and by delays in inquiries, which were often seen to be less than independent. In some cases, it was also compounded by the discourtesy with which the family was treated immediately following their bereavement, including off-hand thoughtlessness in the means used to notify next-of-kin of the death. All of these factors had led the families we met to lose confidence in the capacity of the state to protect people in its care and to deliver justice. It is a loss of confidence which can only be widely shared, and there is an urgent obligation on the Government to reverse it.

7. During our inquiry we were encouraged by examples of good practice which, if adopted more widely throughout our detention system, would go some way towards ensuring respect for the human rights of prisoners and detained mental health patients. There is much theoretical understanding of ways to manage our prisons and mental health units in order to minimise the risks of deaths in custody, and in some cases this understanding has been put into practice, creating an institutional culture which promotes and protects the rights of even the most disturbed people, and which manages incidents of violence in a humane and ethical manner. We draw attention to such examples of good practice throughout our Report.

8. This inquiry has considered problems relating to deaths in prison, in police custody, in immigration service removal centres (formerly known as detention centres) and in Mental Health Act detention. Each form of state custody presents its own difficulties in securing the safety of detainees. Police custody functions as an emergency service, detaining people about whom very little information may be available. These problems are not present to the same extent in the prison service, where, nevertheless, the pressures of overcrowding and of an overstretched prison service affect prisoners' safety.

9. Across all forms of state detention, however, there are common factors present in deaths in custody. The multiple vulnerabilities of the people detained, the acute need for medical treatment and drug and alcohol detoxification facilities, low educational achievement and poor communication skills, and the high rate of mental illness, are all found to a greater or lesser extent in all forms of state detention. The use of physical restraint by the detaining authorities, and its consequences for the safety of those detained, is also a common issue, though the circumstances in which such force is used may vary.

Structure of our Report

10. The duty of the state to protect the life of those in its care provides the framework in which we have placed our examination of the issues raised by this inquiry. This Report seeks to address the challenge of preventing deaths in all forms of state custody, in the context of the right to life, and the related duty to protect other rights of detained people under the European Convention on Human Rights. An integrated human rights approach to deaths in custody requires that the safety of detained people should be protected, not through the exercise of excessive or intrusive control, but in the context of a system which also respects rights to privacy, personal identity and physical integrity. We give a full explanation of the human rights framework in Chapter 2. In Chapter 3 we go on to give an overview of the scale of the problem of deaths in custody, and an explanation of the factors behind the problem.

11. Policy to reduce deaths in custody operates, as we have said, in a context where there are many people detained, especially in prisons, who quite simply should not be there. The decision to hold a person in state detention is an assumption of a heavy responsibility to ensure the safety of someone who may already be at risk, and it is a decision which should be taken in light of the duty to protect the right to life. The problem of self-inflicted deaths in custody therefore cannot be considered in isolation from prison overcrowding and sentencing practice, and the availability to sentencers of alternatives to custodial sentences. We address these background issues in Chapter 4, while remaining conscious that, in overall policy terms, parliamentary scrutiny of such matters is the responsibility of members of the Commons Home Affairs Committee.[1]

12. It is our conviction that, in the long-term, sustainable solutions to the problem of deaths in custody can only be achieved in the context of increased resources and a reduction in the numbers of prisoners and other detainees held in the UK. But significant improvements can be made even within the constraints of the current system. In Chapters 5 to 9, we go on to look at some of the practical aspects of preventing self-inflicted deaths, as well as deaths resulting from neglect. Chapter 5 considers the issues surrounding risk assessment and management of detainees, especially in the crucial early hours, days and weeks following their admission into custody. Individualised risk assessment and clear communication of information in this regard between the various state authorities provides the indispensable bedrock for an effective policy to prevent self-inflicted deaths in custody.

13. In Chapters 6 and 7 we consider the provision of healthcare, physical and mental, in the different detention settings. We then consider issues surrounding the use of physical restraint and seclusion (Chapter 8) and staffing and training issues (Chapter 9). These issues affect both self-inflicted deaths, and deaths resulting from actions of police, prison officers or other staff.

14. Finally, in Chapter 10, we consider the important question of the mechanisms that are in place to investigate deaths in custody. It has been established by jurisprudence of the European Court of Human Rights that the Article 2 ECHR duty to protect life requires a thorough and independent investigation of all deaths in custody. The State has a duty to ensure that the families of those who died are provided with a full explanation of the circumstances of the death and are fully involved in the investigation into those circumstances. It also has a duty to ensure that the investigation is capable of leading to the identification and punishment of those responsible for a death. Our main conclusions and recommendations are set out in Chapter 11.

15. We are most grateful to all those who have assisted us throughout the course of this inquiry. We also record our thanks to our two specialist advisers in the inquiry, Professor Kevin Gournay of the Institute of Psychiatry at King's College London, and Joe Levenson.

1   See, for example, their recent Fifth Report of Session 2003-04, Draft Sentencing Guidelines 1 and 2, HC 1207 Back

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