367. It is clear that there are many and complex
inter-related issues which lie behind deaths in custody. In large
part however our analysis is chillingly simple.
- While crime levels are falling,
we are holding more people in custody than ever before, and for
longer, too many of whom should clearly not be there at all.
- We are holding them in conditions which are often
unsatisfactory or inappropriate to their needs, many of them in
prisons which are increasingly overcrowded, many miles from home.
- We are holding many people who have very special
needs indeed, including those with substance abuse or mental health
problemsmany of whom should be held elsewhere or supervised
within the community and all of whom are particularly vulnerable
and at risk of taking their own lives.
- We are holding them in institutions where the
officers responsible for detention are working under great pressure
and are often required to deal with violent or volatile situations
involving people with complex healthcare and mental healthcare
needs, too often without adequate training or specialist support.
- We are attempting to deal with these problems
within an institutional structure often glaringly ill-suited to
meet the basic needs of detainees, let alone the full panoply
of their human rights, for example by detaining mentally-ill people
in prison because of a shortage of places in high- or medium-secure
- We are failing to provide the resources, in terms
of the physical condition of many our detention facilities and
the numbers of trained staff employed within them, which would
create a more effective environment for the protection of detainees'
- The result is a failure properly to protect the
lives of vulnerable people in the state's care through the positive
measures necessary to meet the duty of care required by the state
in compliance with Article 2 of the European Convention on Human
Rights (ECHR) .
- And when people die in consequence of that failure,
the system does not always offer an effective investigationan
essential requirement of the right to life under Article 2.
- Whilst the aim should be to avoid all deaths
in custody, this is unlikely to be achieved in the present circumstances
and with current resources without instituting a regime which
in itself would infringe human rights.
368. Preventing deaths in custody is an immensely
complex and challenging task. There is no doubt that some of the
most vulnerable people in the country are to be found in our prisons,
special hospitals and other places of detention. There is no doubt
also, that distress caused by detention adds to these vulnerabilities.
369. Prevention of deaths in custody can best be
achieved in a system which takes seriously at every level its
obligation to protect the right to life under Article 2 ECHR,
but which also sustains a culture which respects the dignity,
privacy and autonomy of the people it detains and their rights
under Article 8 and Article 3 ECHR. Emerging findings from research
by the Cambridge Institute of Criminology,
into the impact of the prison service safer custody programme,
suggest that there are significant associations between the quality
of prison life, levels of prisoner distress and an establishment's
rates of self-inflicted death. Aspects of the quality of prison
life that are associated with prisoner distress include distress
on entry, perceived safety, opportunities for personal development
and perceived fairness.
This research shows that the positive obligation to protect people
detained by the State is not only a matter of physical security,
but of the culture of detaining institutions. It places a responsibility
on the State's systems of detention to address the problems faced
by the people they detain, whether imported or arising following
370. We consider that although practical measures
such as the provision of safer cells are valuable and should continue
to be advanced, these measures in themselves will not resolve
the problem of the continuing high rate of deaths in custody.
At the level of the day to day operation of prisons and other
places of detention, the culture of a prison or secure hospital,
the extent to which people are treated with dignity, the quality
of relationships between prisoners and staff, are all critically
important. This is an aspect of suicide prevention which in the
healthcare setting has been termed "relational security."
It is also reflected in the standard against which the Chief Inspector
of Prisons inspects, of a "healthy prison", which meets
standards of decency, safety, and respect. This culture, as research
appears to confirm, is fundamental to prisoner safety, and therefore
to the protection of rights under Article 2.
371. These essential changes cannot be realised without
commitment, both of policy and resources, at the level of central
government. Adequately meeting the complex needs of many of the
people held in detention is inevitably resource-intensive, requiring
not only high levels of staffing, but also highly trained staff,
and high and consistent levels of healthcare, mental healthcare
and detoxification and drug addiction services. It is also extremely
difficult to realise within an overburdened or overcrowded system,
and it is incumbent on the Government to devise alternatives to
custodial sentences, commanding public and judicial confidence,
which can prevent the senseless incarceration of highly-vulnerable
individuals, such as many of the young women we met at Holloway,
imprisoned for very short periods for petty crime.
372. This misplaced over-reliance on the prison system
is at the heart of the problem addressed in this report. Throughout
our inquiry we have seen time and time again the links between
mental illness, drug and alcohol dependencies, short sentences
and potential for self-inflicted death. It must, therefore, be
seen that the imprisonment of such vulnerable people is at the
root of the problem itself. It is not only that this incarceration
is senseless, but that it is in fact the first step on a path
that can lead to the self-inflicted death of one person every
four days, on average, in our custodial system. Until we change
our approach to criminal justice for vulnerable people convicted
of petty crime we cannot begin to meet our positive obligations
under Article 2 and meet our duty of care to them.
373. A further issue which has been highlighted throughout
our inquiry, and in particular in relation to police custody and
Mental Health Act detention, is the lack of central co-ordination
to enforce standards and train staff in areas relevant to deaths
in custody. This has allowed examples of good practice to remain
isolated, and essential guidelines which underpin human rights
protection, to take insufficient effect in practice.
374. Neither has there been significant sharing of
information and good practice between the police, prison service
and NHS. The problem of deaths in custody has not been neglected
by government or public bodies. Evidence to this inquiry has detailed
a wealth of initiatives which have sought to research and address
aspects of the problem. In this Report we have noted a number
of examples of good practice which can assist in changing the
culture of detention establishments to ensure better protection
of detainees' rights and a reduction in the incidence of deaths
in custody. However, these disparate initiatives have not been
effective in tackling the scale of the problem.. They are very
far from having reached the stage where they might be considered
to have become firmly established in the institutional and cultural
norms of our prisons, police stations, immigration removal centres
and mental health units. Greater urgency in eliminating bad practice
and spreading good practice throughout these institutions is badly
needed. In numerous areas the issues surrounding deaths in custody
are similar, regardless of whether they are being faced by our
prisons, our hospitals, our police stations or our inquiry bodies.
This applies to healthcare, physical and mental, risk assessment
and management, dealing with violent behaviour, training staff,
and devising satisfactory procedures for inquests.
375. Our principal conclusion is therefore that
there is a need for a central forum to address the significant
national problem of deaths in custody. One existing model for
such work is the cross-government group on the management of violence,
which is working towards the production of joint guidance on the
use of restraint and other responses to violence, applicable across
prison, police, and mental health act detention. We consider,
however, that a permanent body, with a remit to address all aspects
of deaths in custody, is required.
376. We recommend that the Home Office and the
Department of Health, as the main responsible departments, should
establish a cross-departmental expert task-force on deaths in
custody. This should be an active, interventionist body, not a
talking-shop, with its membership drawn from people with practical
working experience of the problems associated with deaths in custody.
The task-force should also have at its disposal human rights expertise.
Broadly, the functions and powers of such a body should be
- To share information on
good practice in preventing deaths in custody between each form
- To develop guidelines on matters relating
to prevention of deaths in custody;
- To review systems for the investigation of
deaths in custody and to seek to establish consistency in such
- To develop consistent good practice standards
on training in issues relating to deaths in custody;
- To review recommendations from coroners, public
inquiries and research studies, to consider how they can be taken
forward, and to monitor progress in their implementation;
- To collect and publish information on deaths
- To commission research and to make recommendations
to Government. Where such recommendations involve expenditure
we would expect the Government to meet the needs where funding
was clearly necessary to ensure observance of ECHR rights.
393 Led by Dr Alison Liebling Back
HC Deb., 10 February 2004, col. 1437W Back