Source · Deaths in custody oversight
Independent Advisory Panel on Deaths in Custody
Thematic reports, panel guidance, commissioned research and case investigations on deaths and serious harm in state custody, each linking to the panel's own publication.
115 reports
262 recommendations
3 with a response
19 case investigations
Independent Advisory Panel on Deaths in Custody ↗Article 2 case investigations
Reports 115 matching reports
Independent investigation into an incident of life-threatening self-harm involving ‘MT’[1] at HMP Bristol on 15 January 2018
Independent investigation into an incident of life-threatening self-harm involving ‘Mr Idris’[1] at HMP Swansea on 24 October 2015
Independent investigation into an incident of serious assault involving ‘AE’[1] at HMP Nottingham on 2 June 2015
IAPDC Chair’s end of term report – February 2026
Guidance on preventing suicides in and following police custody in England and Wales
Written by this site Produced collaboratively by the College of Policing, the National Police Chiefs’ Council (NPCC), and the Independent Advisory Panel on Deaths in Detention (IAPDC) – this guidance sets out a preventative, evidence-informed approach to the risk of suicide in and following police custody. It draws on best practice and the expertise of a broad range of stakeholders across policing, justice, health, and the third sector who participated in a series of working groups to provide a comprehensive framework for identifying and responding to suicide risk throughout custody – from arrest to release. It highlights the importance of early intervention, person-centred care, continuity of care and coordinated multi-agency support.
Investigating deaths under the Mental Health Act: The need for independence and parity
Written by this site Thematic report calling for independent investigation of deaths of patients detained under the Mental Health Act, with parity of process to deaths in other forms of state detention. Contains 4 recommendations.
Prison Overcrowding and Deaths in England and Wales: Findings from a Predictive Analysis and Modelling Study
Written by this site Predictive analysis examining the association between prison overcrowding and deaths in custody (2014-2024). Projects that self-inflicted deaths could increase by 21% by 2029. Contains 3 strategic recommendations.
Ligature Deaths in Prisons in England and Wales: Trends and Reduction Strategies
Written by this site Analysis of ligature death trends in prisons (1999-2024). Finds ligature deaths account for 89% of self-inflicted deaths. Contains 12 recommendations across cell design, monitoring, risk assessment and research.
PL investigation report
Written by this site PL investigation report
Response to PL independent investigation
Written by this site Response to PL independent investigation
AR investigation report
Written by this site Report of an investigation into the circumstances of an act of self-harm by AR at HMP Norwich
SR investigation report
Written by this site Report of an Independent Investigation into the Case of SR commissioned by the Secretary of State for Justice in accordance with Article 2 of the European Convention on Human Rights.
Response to SR Independent Investigation
Written by this site Response to SR Independent Investigation
Response to AR independent investigation
Written by this site Response to AR independent investigation
IAPDC Chair’s mid-term report – February 2023-August 2024
Written by this site Lynn Emslie, Chair of the Independent Advisory Panel on Deaths in Detention, mid-term report - February 2023-August 2024
Assessing the Risk Factors Contributing to Premature Mortality among Detained Psychiatric Patients: A Scoping Review
Written by this site A scoping review to systematically examine the current understanding of risk factors associated with premature mortality among detained individuals in hospital settings.
Assessing the Risk Factors Contributing to Premature Mortality among Detained Psychiatric Patients: A Scoping Review
Written by this site A report published by the IAPDC which assesses the risk factors contributing to premature mortality among detained patients.
HM – HMPPS response to recommendations
Written by this site Action Plan in response to the independent investigation in the case of 'HM', who was seriously assaulted at HMP High Down on 30 October 2015
CR – HMPPS response to recommendations
Written by this site HMPPS response to recommendations from the CR investigation report.
DM – HMPPS response to recommendations
Written by this site HMPPS response to recommendations from the 'DM' independent investigation report.
Mr Everest – HMPPS response to recommendations
Written by this site HMPPS response to the independent investigation in the case of 'Mr Everest'
Mr Midland – HMPPS response to recommendations
Written by this site HMPPS response to recommendations contained in the independent investigation in the case of 'Mr Midland'.
IAPDC statistical analysis of recorded deaths in custody between 2017 and 2021
Written by this site A report published by the IAPDC which provides a statistical analysis of recorded deaths in custody between 2017 and 2021.
Mr Quartz investigation report
“It’s time things change”: Priorities for detention for the Department of Health and Social Care’s suicide prevention strategy
Written by this site Thematic report setting out the Panel's priorities for detention settings to inform the Department of Health and Social Care's suicide prevention strategy. Contains 42 recommendations across staff culture, multi agency working, self-harm and suicide prevention, family involvement, the custodial environment, and learning and accountability.
More Than a Paper Exercise: Enhancing the Impact of Prevention of Future Death Reports
Written by this site Review of how Prevention of Future Death reports are used across the custody system. Examines the role of coroners, recipients, and oversight bodies. Contains 18 recommendations for improving the impact and follow-up of PFD reports.
IAPDC and HMPPS agreement on reducing and preventing deaths in prison (July 2023)
The Fulton Report: Review of the forum for preventing deaths in custody – Robert Fulton
Written by this site Review of the forum for preventing deaths in custody - report of the independent reviewer
Special Rapporteur on extrajudicial, summary or arbitrary executions call for input on deaths in custody
Written by this site IAPDC's response to Special Rapporteur on extrajudicial, summary or arbitrary executions call for input on deaths in custody.
UN Special Rapporteur on extra-judicial, summary, or arbitrary executions call for input on deaths in custody
Written by this site Submission of evidence to the UN Special Rapporteur on extra-judicial, summary, or arbitrary executions call for input on deaths in custody.
End of term report – February 2023
Written by this site Juliet Lyon, Chair of the Independent Advisory Panel on Deaths in Detention, end of term report - February 2023
Preventing Deaths at Point of Arrest, During and After Police Custody
Written by this site Thematic report examining deaths at point of arrest, during police custody and apparent post-custody suicides. Based on evidence gathering exercise with police forces, PCCs, healthcare providers and bereaved families. Contains 25 recommendations.
Response to the Prisons Strategy White Paper consultation
Written by this site Independent Advisory Panel on Deaths in Detention Response to the Prisons Strategy White Paper consultation
Protecting Lives: A Cross-System Approach to Addressing Alcohol and Drug-Related Deaths within the Criminal Justice System
Written by this site Joint report with the Royal College of General Practitioners examining cross-system approaches to preventing drug and alcohol-related deaths in all forms of state custody. Contains 10 recommendations.
Mr Midland – investigation report
Written by this site Final report of an independent investigation into the case of Mr Midland.
HM – investigation report
Written by this site Final report of an independent investigation into the case of HM commissioned by the Secretary of State for Justice in accordance with Article 2 of the European Convention on Human Rights
Justice Select Committee inquiry on ‘mental health in prison’
Written by this site Independent Advisory Panel on Deaths in Detention submission to the Justice Select Committee call for evidence on mental health in prisons.
NHS England response to Rob Allen report (10 May 2021)
Written by this site NHS England response to Rob Allen investigation report
Response to Reforming the Mental Health Act White Paper
Written by this site The Independent Advisory Panel on Deaths in Detention response to Reforming the Mental Health Act White Paper
The Independent Human Rights Act Review
Written by this site Independent Advisory Panel on Deaths in Detention (IAPDC) – response to the Independent Human Rights Act Review (IHRAR) call for evidence
Criminal justice joint evidence review on ‘neurodiversity in the criminal justice system’
Written by this site Response to the HMIP evidence review on neurodiversity in the criminal justice system.
AD investigation – update on the Brunel unit
Written by this site Independent investigation in the case of 'AD': update on the Brunel unit
Priorities for a prevention of death strategy in Immigration Removal Centres
Written by this site Thematic report and action plan setting out priorities for a prevention of death strategy across Immigration Removal Centres. Contains 24 recommendations addressed to the Home Office and partners.
Justice Select Committee inquiry on ‘the future of legal aid’
Written by this site Independent Advisory Panel on Deaths in Detention submission to the inquiry by the Justice Committee on the Future of Legal Aid – October 2020
Avoidable Natural Deaths in Prison Custody: Putting Things Right
Written by this site Joint report with the Royal College of Nursing examining avoidable natural deaths in prison custody. Contains 15 recommendations for improving healthcare provision and reducing preventable deaths.
Centre for Mental Health’s review to guide the future of prison mental health care in England
Written by this site Independent Advisory Panel on Deaths in Detention submission to the Centre for Mental Health’s review to guide the future of prison mental health care in England.
Home Affairs Select Committee inquiry on ‘black people, racism and human rights’
Written by this site Independent Advisory Panel on Deaths in Detention submission to the inquiry by the Joint Committee on Human Rights on black people, racism and human rights – September 2020
HMPPS response to Dale Simon report
Written by this site HMPPS response to Dale Simon report - Independent assessment of allegations of unprofessional conduct: review of HMPPS internal investigation.
Final JL report – Professor McDougall
Written by this site Report of an Investigation under Article 2 of the European Convention of Human Rights into the circumstances surrounding the attempted suicide of Mr JL at HMYOI Feltham on 19 August, 2002
Publication coverage
The full indexed collection, by year and by custody sector.
Reports by year
Read the chart values
| Year | Reports |
|---|---|
| 2007 | 1 |
| 2009 | 1 |
| 2010 | 4 |
| 2011 | 10 |
| 2012 | 2 |
| 2013 | 6 |
| 2014 | 2 |
| 2015 | 3 |
| 2016 | 4 |
| 2017 | 6 |
| 2018 | 16 |
| 2019 | 8 |
| 2020 | 9 |
| 2021 | 8 |
| 2022 | 3 |
| 2023 | 7 |
| 2024 | 10 |
| 2025 | 10 |
| 2026 | 5 |
By custody sector
Read the chart values
| Custody sector | Reports |
|---|---|
| Prisons & Probation | 22 |
| Police Custody | 5 |
| Immigration Detention | 1 |
| Mental Health Act Detention | 12 |
| Cross-cutting | 75 |