Source · Deaths in custody oversight
Independent Advisory Panel on Deaths in Custody
60 reports
262 recommendations
3 with response
19 case investigations
Thematic reports, panel guidance, commissioned research and case investigations examining deaths and serious harm in state custody. Source: iapondeathsincustody.org.
Article 2 Investigations: Deaths and Near-Deaths in Custody
19 individual case investigations into deaths, near-deaths, serious self-harm and assaults in prison custody, commissioned under Article 2 ECHR
Reports
31 Oct 2025
Police Custody
Guidance on preventing suicides in and following police custody in England and Wales
Guidance
Produced collaboratively by the College of Policing, the National Police Chiefs’ Council (NPCC), and the Independent Advisory Panel on Deaths in Custody (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.
8 Oct 2025
Mental Health Act Detention
Investigating deaths under the Mental Health Act: The need for independence and parity
Thematic Report
4 recs
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.
4 recommendations
I.
DHSC sponsors the establishment of a new independent mechanism, utilising existing resources and organisations, to conduct investigations into deaths occurring under MHA detention. This could be set up as part of one distinct body, or through collaborative work across existing …
II.
All deaths in MHA detention be investigated – both ‘non-natural’ and ‘natural’.* As part of this, we recommend that a ‘panel’ approach (as explored more below) be adopted to ensure appropriate clinical resources are allocated to each investigation.
IV.
The investigative mechanism draws on existing expertise to help shape the clinical review structure and training for clinical reviewers for the investigation of these deaths, collaborating with bodies such as the Parliamentary and Health Services Ombudsman (PHSO) and HSSIB.
III.
Clinical leadership is embedded within the independent investigative mechanism itself. At the very least, this mechanism should have its own clinical leadership to direct, oversee, and quality assure externally commissioned clinical advice. Further scoping may be needed to ensure that …
5 Sep 2025
Prisons & Probation
Prison Overcrowding and Deaths in England and Wales: Findings from a Predictive Analysis and Modelling Study
Rapid Evidence Collection
3 recs
No formal response
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.
Government response summary
No formal government response published. Report published September 2025.
3 recommendations
1.
Expand healthcare provision, particularly mental health services, in high-risk environments such as Category B male prisons.
2.
Target suicide and self-harm prevention in prisons with occupancy rates at or above 100%.
3.
Enable establishment-level research by allowing routine data sharing with independent research teams to better understand mortality risks and how to mitigate them.
1 Aug 2025
Prisons & Probation
Ligature Deaths in Prisons in England and Wales: Trends and Reduction Strategies
Thematic Report
12 recs
No formal response
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.
Government response summary
No formal government response published. Report discussed at Ministerial Board on Deaths in Custody (November 2024) prior to final publication. Report published April 2025.
12 recommendations
1.
Encourage cross-establishment sharing of prison audit findings to improve consistency in cell design and suicide prevention approaches between prisons, so that priorities and action plans could be identified to establish a national ligature death prevention strategy.
2.
Establish national "minimum expectations" in cell ligature safety standards.
3.
Review and remove ligature points in both new-built and old cells (particularly those on windows, beds, and doors or cell gates) while maintaining an unrestrictive and humane environment, with reference to cellular accommodation design guides and checklists.
4.
High-priority areas should be identified to guide ongoing work addressing ligature points such as windows in older prisons, with progress reviewed regularly.
5.
Personnel involved in designing ligature-resistant cells should recognise that a low height of ligature point does not indicate safety.
6.
Explore the usability of alternative materials for ligature-resistant bedding in cells.
7.
Establish criteria in the level of supervision required for 'at risk' prisoners to ensure prompt response to ligature use events by staff.
8.
Improve information sharing and communication between prison staff and other professionals, particularly with healthcare services.
9.
Post-incident early reviews should be conducted to identify factors, including potential ligature points in prisoners' environment, which may have been inadequately addressed to prevent death.
10.
Risk assessment and intervention frameworks should be evidence-based (e.g., by considering findings from high quality research identifying risk factors).
11.
Improve risk assessment by incorporating findings of new evidence on role of structured approaches to support professional decision-making, particularly at the end of the ACCT process.
12.
Encourage collaboration between prison establishments and researchers to evaluate impact of changes to policies and efficacy of existing and new suicide prevention strategies.
4 Nov 2024
Cross-cutting
IAPDC Chair’s mid-term report – February 2023-August 2024
Chair's Report
Lynn Emslie, Chair of the Independent Advisory Panel on Deaths in Custody, mid-term report - February 2023-August 2024
9 Aug 2024
Mental Health Act Detention
Assessing the Risk Factors Contributing to Premature Mortality among Detained Psychiatric Patients: A Scoping Review
Thematic Report
A report published by the IAPDC which assesses the risk factors contributing to premature mortality among detained patients.
9 Aug 2024
Mental Health Act Detention
Assessing the Risk Factors Contributing to Premature Mortality among Detained Psychiatric Patients: A Scoping Review
Thematic Report
A scoping review to systematically examine the current understanding of risk factors associated with premature mortality among detained individuals in hospital settings.
23 Apr 2024
Cross-cutting
IAPDC statistical analysis of recorded deaths in custody between 2017 and 2021
Statistical Analysis
A report published by the IAPDC which provides a statistical analysis of recorded deaths in custody between 2017 and 2021.
12 Sep 2023
Cross-cutting
“It’s time things change”: Priorities for detention for the Department of Health and Social Care’s suicide prevention strategy
Thematic Report
42 recs
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.
42 recommendations
1.
Annual, mandatory training should be given to frontline staff to ensure they adopt a person-centred and trauma-informed approach to providing support to individuals under their care. Detention settings should adopt OHID’s working definition of trauma-informed practice.
2.
Staff training on responses to mental health crises should involve input from people with lived experience and families bereaved by suicide. Staff themselves should be given the opportunity to inform training content as well.
3.
Detention settings should draw on learning from community postvention initiatives and the postvention initiative in prisons being developed in collaboration with the Samaritans to ensure people in detention and staff are supported when a death does occur.
4.
Safety impact assessments should be introduced across detention settings to ensure that all policy proposals include assessment of their likely impact on the health and safety of detainees and the staff charged with their care.
5.
The transfer of information between different teams in individual custodial institutions, as well as with external agencies and organisations across the criminal justice system, needs to be improved. This should include the revision of robust memorandums of understanding between relevant …
6.
Mental health services need to be universally available to individuals in detention and properly resourced.
7.
Greater resource is required to ensure more hospital beds are available to ensure transfers from prisons or IRCs to hospital for individuals with severe mental health needs requiring hospital treatment are done within the 28-day limit proposed in the draft …
8.
Tailored, multidisciplinary support is needed to address the often complex and diverse needs of female prisoners.
9.
Release planning for detainees should be improved to prevent post-custody deaths. This should always involve input from core services, such as health, housing, and addiction treatment. Services should ensure each establishment has staff with clear responsibilities for making sure arrangements …
10.
End-to-end systems of support should be put in place for people leaving all forms of detention. This is particularly important for individuals deemed at higher risk, such as those leaving police custody accused of child sex abuse and indecent image …
11.
More health-based places of safety are needed to ensure individuals detained and transported under Section 135 and 136 of the Mental Health Act can be managed safely and in a timely manner.
12.
DHSC should lead work with the Home Office to ensure targeted resources and improved systems are in place to make sure mental health professionals, not police officers, are the first responders to individuals experiencing a mental health crisis.
13.
Detention staff involved in care planning processes should make sure that non-clinical risks, such as negative parole outcomes and a lack of social visits, form part of self-harm and suicide prevention conversations and actively inform interventions.
14.
Safety interviews and assessments should always take place in private to encourage detainees to share information about their mental health, wellbeing, and any concerns they may have openly and honestly.
15.
Risks should be recorded in one place to enable easy and quick access to up-to-date information on detainees’ vulnerabilities and needs. This should include healthcare information. Plans contained within the Prisons Strategy White Paper to create a single digital prisoner …
16.
Detention settings should review processes to ensure a multidisciplinary approach is taken to supporting the mental health needs of detainees. Healthcare staff should be involved in self-harm and suicide prevention processes to ensure support is not fragmented.
17.
Information on the Rule 35 process should be translated into a variety of languages and be readily available for detainees in immigration detention. An independent review of Rule 35 should be commissioned with the importance of protecting those at risk …
18.
Individuals in immigration detention placed on an ACDT should be automatically referred for a mental health assessment.
19.
Self-harm and suicide prevention processes should be used at an earlier stage than when the detainee is at the point of crisis in order to maximise the efficacy of interventions.
20.
Leadership in individual prisons should take responsibility to ensure peer support programmes, particularly the Samaritans Listener scheme, are in place, supported, and prioritised.
21.
Where appropriate and with consent, families should routinely be involved in ACCT reviews and care planning processes for individuals identified at risk of self-harm or suicide. Staff must facilitate this and respond promptly to issues raised.
22.
Consent to contact families about mental healthcare concerns should be sought from individuals early on during their detention and kept under review.
23.
Places of detention must have working, adequately resourced phone lines to ensure families can promptly escalate concerns about prisoners’ wellbeing. A dedicated phone line for families should be introduced across all detention settings.
24.
In-cell telephony should be rolled out across the prison estate. In the interim, a flexible approach should be taken by staff to ensure vulnerable prisoners can contact their families as a means of support.
25.
Individuals in IRCs without close family ties should be empowered to access support provided by charities supporting detainees.
26.
Where possible, individuals should be detained close to their homes, families, and communities to ensure they have access to support. Where this is not possible, schemes to facilitate visits, such as help with travel costs and accumulated visits, should be …
27.
Proactive steps should be taken to review and remove ligature points in accommodation across all detention settings.
28.
Physical conditions across detention settings should be improved to benefit good mental health. For instance, examples of good practice are already taking place across several police forces which should be shared with and embedded across all forces as well as …
29.
Alternative provision is needed to ensure custodial settings can reduce inappropriate use of segregation. Its use should not be a means to prevent self-harm and suicide.
30.
The provision of care suites for individuals in crisis should be rolled out across the immigration detention estate.
31.
Out of area placements for individuals detained under the Mental Health Act should be eliminated, as outlined in the Five Year Forward View for Mental Health, to enable patients to receive care closer to their support networks.
32.
Alternatives to remand and non-custodial sentences should be prioritised, where possible. Sentencing decisions should be informed by high-quality pre-sentence reports. Training for staff is needed to improve the quality of, and thereby increase judicial confidence in, pre-sentence reports.
33.
Indeterminacy for patients detained under the Mental Health Act should be minimised. Where possible, they should be given a clear timetable for their discharge. Similarly, information should be given to detainees in IRCs on the process of their release in …
34.
Detention settings should invest in interpretation services to ensure detainees are able to access information and support and can communicate their emotions and concerns.
35.
Prisoners should be given access to daily activities which promote their sense of purpose and wellbeing. Staff recruitment and retention, to facilitate purposeful regimes, is a key aspect of this.
36.
An independent body with an investigative function, similar to that carried out by the PPO and IOPC, should be established to investigate deaths under the Mental Health Act.
37.
Departments should consider the establishment of a function to monitor Article 2 compliance to ensure learning from investigations and inquiries is fully acted on and shared.
38.
Staff shadowing opportunities should be made available across detention settings to facilitate sharing and embedding of learning and good practice.
39.
Places of detention must be open to and facilitate research on self-inflicted deaths to develop an evidence base for interventions.
40.
Research should focus on diversity within detention settings, factoring in the different experiences of, for example, women, young people, and ethnic minority groups.
41.
Research in detention settings which have a lower incidence of completed suicides should focus on ‘near misses’ and attempted suicides.
42.
DHSC should produce high-quality, disaggregated data on deaths of people detained under the Mental Health Act to enable an in-depth understanding of deaths across different population groups.
1 Sep 2023
Cross-cutting
More Than a Paper Exercise: Enhancing the Impact of Prevention of Future Death Reports
Thematic Report
18 recs
No formal response
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.
Government response summary
No formal government response published.
18 recommendations
1.
All should ensure that their approach to the PFD process is open, non-defensive and that the public interest in preventing future deaths is prioritised over reputational considerations at every stage. For example, lawyers should be specifically instructed not to take …
2.
All should ensure that they approach the PFD process with full candour and proactively provide all relevant information at the earliest appropriate stage.
3.
The Ministry of Justice (MoJ) should adequately resource the Chief Coroner's Office to produce a yearly review of PFD reports for custody deaths. This should aim to identify themes and trends, and report on the timeliness and quality of responses, …
4.
The MoJ should provide dedicated funding to the Chief Coroner's Office to enable it to centrally record the conclusions of inquest juries, even where no PFD report is issued, and publish them online for easy referral in the same way …
5.
The Department of Health and Social Care (DHSC) should give serious consideration to the creation of an independent body for investigating deaths of those formally or informally detained in mental health settings. This would remove the anomaly between the investigation …
6.
Recipients of PFD reports relating to deaths in custody should hold a "post-inquest learning review" meeting following the conclusion of an inquest, attended by the key persons who participated in the inquest. This will help to ensure both an efficient …
7.
Recipients of PFD reports should ensure that their responses are timely, high quality, case-specific, and fully informed by the inquest evidence and findings. Where the response relays that action will be taken, actions should be identified in precise terms and …
8.
All should ensure PFD reports are shared 'horizontally' with relevant equivalents across the country – for example, other police forces, prisons, and mental health trusts – particularly where there may be scope for national learning, to ensure opportunities to make …
9.
Leaders of local custody bodies, such as prison governors, should consider adopting the approach of Milton Keynes Together Safeguarding Partnership and hold periodic meetings of representatives from all custodial settings to review relevant PFD reports, with participation, where appropriate, of …
10.
Government should consider what enhanced role independent bodies might play in auditing, following up on, and reporting on PFD reports, and this could include establishing a new body for this purpose. More effective oversight of the sharing, use, and implementation …
11.
The Chief Coroner should consider supplementing his guidance on PFD reports to further address when it may be appropriate, in compliance with the statutory requirements, to make interim PFD reports and the importance of doing so, in particular where a …
12.
The Chief Coroner should consider supplementing his guidance to advise coroners on the importance of ensuring relevant evidence is provided at a sufficiently early stage, in particular where coroners consider there may be a need for urgent action. The guidance …
13.
The Chief Coroner's Office should review and consider expanding the list of organisations which should receive PFD reports on deaths in state custody (found at paragraphs 56 and 57 of the guidance on PFD reports) to ensure more comprehensive coverage …
14.
The Chief Coroner's Office should ensure that its online database of PFD reports is fully searchable by thematic areas and location, and that deaths in detention (particularly under the Mental Health Act 1983 (MHA) are readily identifiable. Consideration should be …
15.
The Ministerial Board on Deaths in Custody secretariat should send PFD reports on deaths in custody to the House of Commons Justice, Health, and Home Affairs Select Committees, which should consider taking evidence and reporting on significant themes.
16.
All organisations which scrutinise places of detention should make explicit use of PFD reports to inform their investigations, inspections, and thematic reports and bulletins, including monitoring and reporting on progress made against responses to PFD reports by services and agencies. …
17.
The Ministerial Board on Deaths in Custody (MBDC) secretariat should continue to review and distribute PFD reports relating to death in custody to MBDC members for the purpose of sharing learning, and consider involving all relevant agencies and partners who …
18.
The Judicial College should work with the Chief Coroner to deliver mandatory training to coroners on the purpose, process, publication, and distribution of PFD reports, as well as the role of independent scrutiny bodies, incorporating the perspective of bereaved families.
29 Jul 2023
Prisons & Probation
IAPDC and HMPPS agreement on reducing and preventing deaths in prison (July 2023)
Guidance
21 May 2023
Cross-cutting
The Fulton Report: Review of the forum for preventing deaths in custody – Robert Fulton
External Research & Analysis
Review of the forum for preventing deaths in custody - report of the independent reviewer
28 Feb 2023
Cross-cutting
End of term report – February 2023
Chair's Report
Juliet Lyon, Chair of the Independent Advisory Panel on Deaths in Custody, end of term report - February 2023
1 Dec 2022
Police Custody
Preventing Deaths at Point of Arrest, During and After Police Custody
Thematic Report
25 recs
Response Sep 2024
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.
Government response summary
No direct formal response to the 25 recommendations. Policing Minister Rt Hon Dame Diana Johnson DBE MP wrote a general response (20 September 2024) on related topics including post-custody suicides, Right Care Right Person, and diversion from custody. The Minister stated commitment to preventing deaths in custody and ensuring transparency and accountability, but did not address specific recommendations. Association of Police and Crime Commissioners published updated guidance for policing leaders on preventing deaths (April 2025) drawing on the IAPDC report.
25 recommendations
1.
Individual forces and healthcare partners should develop and implement an agreement about mental health response in their area. Building on progress made by the cross-agency Mental Health Crisis Care Concordat, understanding must be developed and shared of what support is …
2.
Steps should be taken to ensure a greater scale and coverage of mental health support. Although general healthcare, including within police custody, is usually provided on a 24-hour basis, mental health support through liaison and diversion services is patchier during …
3.
Police and Crime Commissioners should scrutinise the use of adequate risk assessment procedures and protocols on safeguarding for suicide prevention, drug and alcohol misuse. This includes markers on the Police National Computer, medication checks, and monitoring of protection of vulnerable …
4.
While we recognise the range of existing training available for forces, individual forces and liaison and diversion staff, supported by the College of Policing, NHS England, Royal College of Nursing, and the National Police Chiefs Council mental health and neurodiversity …
5.
The Department of Health and Social Care and the Home Office must end the use of police custody as a place of safety, as recommended by Sir Simon Wessely in his review and the intent set out in the Reforming …
6.
NHS Integrated Care Boards and Foundation Trusts must take steps to ensure adequate inpatient facilities are available for urgent admission under the Mental Health Act. The onus for this should not be placed on frontline police officers.
7.
Individual forces should liaise with liaison and diversion services, local health providers and community and voluntary sector organisations to explore options for support available on release for any person identified as at risk of self-inflicted death. This could be strengthened …
8.
NHS England and NHS Wales should consider a further large-scale independent evaluation of liaison and diversion services across England and Wales to assess their current effectiveness and to identify what areas of the programme could be improved to better support …
9.
Individual forces should consider how data on apparent post-custody suicides can be improved. This could include assessing whether reported data accurately reflects deaths which occur later than 48 hours after release. There should be a review of what support and …
10.
Relevant policing, health and local authority partners should work together to standardise aspects of pre-release risk assessments conducted to identify vulnerabilities and in particular indicators of increased suicide risk, with follow-ups put in place where a risk is identified.
11.
Individual forces should evaluate and apply interventions to support the reduction of post-custody suicides, with learning and good practice shared with police in other geographical areas.
12.
Individual forces, with the College of Policing, should identify and share the mechanisms they use for acting on learning after a death. This could involve a more standardised, consistent approach, and the distilling and sharing of relevant coroners' or Independent …
13.
The College of Policing should ensure that training for custody officers and their Authorised Professional Practice (APP) for custody is regularly reviewed and kept up to date, having considered any learning and recommendations following custody deaths. The College of Policing …
14.
Individual forces, the IOPC, the National Police Chiefs Council, the College of Policing, and any other relevant parties to an incident relating to a death should take steps to ensure emerging learning from deaths is shared as a priority following …
15.
Individual forces should integrate the views and perspectives of bereaved families into their processes for learning from a death, and ensure steps taken in response are communicated clearly and respectfully to families during and after implementation.
16.
Individual forces and the IOPC should explore how to define and record 'near miss' incidents and their investigation. Data on, and findings from, near misses should then be collated and shared to inform learning and training to avoid such incidents …
17.
The IOPC and the Home Office should work to provide further information about deaths that are currently recorded under the general classification of 'other deaths following police contact', particularly providing key details regarding themes and learning taken from these deaths. …
18.
Individual forces should take steps to ensure a proactive learning approach when responding to lessons following a death or near miss. This could involve an independent facilitator in lessons-learned exercises after a critical incident in custody. This could provide unbiased …
19.
Individual forces should make use of national seminars to share and discuss best practice. These could be focused on specific topics and be organised in conjunction with other stakeholders. As described by the Durham PCC, these conferences can be held …
20.
Individual forces, the National Police Chiefs Council (NPCC), the College of Policing and PCCs should take steps to improve how they share with colleagues elsewhere the practice in the three thematic areas covered by this report. This exercise highlighted several …
21.
Individual forces, the Home Office, the NPCC, the IOPC and the College of Policing should take active steps to build and disseminate a greater understanding of the role of disproportionality and race in relation to deaths in police custody, particularly …
22.
PCCs should lead local scrutiny panels and expand their focus to include the examination of data relating to custody performance. These panels could focus on data relating to disproportionality, as well as mental health and substance misuse prevalence.
23.
Individual forces must prioritise safety within the broader culture of custody suites. This includes placing emphasis on keeping people safe in custody and looking after them properly with compassion and dignity, as set out by the Good Police Custody guide …
24.
Police and Crime Commissioners should appoint a Portfolio Lead for the prevention of deaths in custody and apparent post-custody suicides. This individual should work alongside the Policing Minister, the police and the IAPDC to drive forward work to reduce the …
25.
Police custody healthcare teams, liaison and diversion services, NHS England and NHS Wales should take an integrated approach to facilitating the treatment of detainees, especially given evidence of co-morbidity and the prevalence of drug and alcohol misuse together with mental …
24 Feb 2022
Prisons & Probation
Response to the Prisons Strategy White Paper consultation
Consultation Response
Independent Advisory Panel on Deaths in Custody Response to the Prisons Strategy White Paper consultation
14 Jan 2022
Cross-cutting
Protecting Lives: A Cross-System Approach to Addressing Alcohol and Drug-Related Deaths within the Criminal Justice System
Joint Report
Joint with Royal College of General Practitioners
10 recs
Response Mar 2022
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.
Government response summary
Joint response from MBDC Ministers Kit Malthouse MP, Victoria Atkins MP, and Gillian Keegan MP (15 March 2022). The response noted the report "with interest" and stated the government's 10-Year Drugs Strategy "From harm to hope" (December 2021) aligns with a number of IAPDC recommendations. Specific actions cited: exploring long-acting buprenorphine availability in prisons, and supplying naloxone to staff in prisons and approved premises. No per-recommendation commitments made.
10 recommendations
1.
The number of substance misuse-related deaths in the criminal justice system is still unclear. The last dataset analysed for deaths in prison is now five years old. The Office for National Statistics (ONS) and HMPPS should collaborate again on a …
2.
The use of naloxone as a form of harm-reduction for opioid abuse should be expanded, with training provided to prison staff (and members of the public) to raise awareness of overdose response. The use of naloxone would help prevent deaths …
3.
While funding has been sourced for the rollout of some Court-based Liaison and Diversion services (L&D) and Community Sentence Treatment Requirements (CSTRs), additional resources are still required to ensure greater coverage. Both initiatives help divert individuals with substance misuse problems …
4.
Drug and alcohol misuse is often associated with, or caused by, wider social and economic issues. A streamlined approach which encourages services to be collaborative, and ideally co-located, is required to enable services to work in an integrated way in …
5.
NHS England and NHS Wales, HMPPS and the Ministry of Justice should set out a specific approach to substance misuse treatment for women in the criminal justice system and wider community health to account for the large catchment areas of …
6.
People are at particular risk of substance misuse-related death when they are in transition between prison and the community. The introduction of 'bridging liaison' roles, created jointly by HMPPS and NHS England and NHS Wales, would reduce the risk of …
7.
The increased use of the newly available formulation of prolonged-release buprenorphine as an opioid substitution therapy (OST), given as weekly or monthly injection, would help to reduce risk and improve the continuity of treatment to service users as they move …
8.
To enable the learning of lessons by services and establishments following a substance-related death, independent recommendations made by investigators and scrutiny bodies should be given to specific owners and made with the clear appreciation as to what changes are realistically …
9.
Investigators of substance misuse-related deaths should take into account both the clinical and security factors relevant to the incident. Where possible, scrutiny bodies should identify where there had been missed opportunities for diversion. Staff from the relevant agencies should be …
10.
NHS England and Health Inspectorate Wales should work in collaboration with investigators to ensure commissioned independent clinical reviewers who assist in investigations into substance misuse-related deaths are qualified and experienced in the subject area. Experienced reviewers should also be involved …
20 May 2021
Mental Health Act Detention
Justice Select Committee inquiry on ‘mental health in prison’
Consultation Response
Independent Advisory Panel on Deaths in Custody submission to the Justice Select Committee call for evidence on mental health in prisons.
24 Apr 2021
Mental Health Act Detention
Response to Reforming the Mental Health Act White Paper
Consultation Response
The Independent Advisory Panel on Deaths in Custody response to Reforming the Mental Health Act White Paper
1 Mar 2021
Cross-cutting
The Independent Human Rights Act Review
Consultation Response
Independent Advisory Panel on Deaths in Custody (IAPDC) – response to the Independent Human Rights Act Review (IHRAR) call for evidence
29 Jan 2021
Cross-cutting
Criminal justice joint evidence review on ‘neurodiversity in the criminal justice system’
Consultation Response
Response to the HMIP evidence review on neurodiversity in the criminal justice system.
24 Oct 2020
Immigration Detention
Priorities for a prevention of death strategy in Immigration Removal Centres
Thematic Report
24 recs
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.
24 recommendations
1.
Improve the transparency of data in relation to deaths in detention by improving Home Office website signposting and through publication of a quarterly statistical report. Provide disaggregated data covering ethnicity, age, location, possible risk groups, type of death (in progress).
2.
To improve transparency and improve learning, expand the definition of a ‘death’ in an IRC, for example by collecting and publishing details of detainees who die in prison while under immigration powers and those who die shortly after leaving detention …
3.
Introduce reporting to mirror that of HMPPS to provide notification of deaths to key external stakeholders.
4.
Develop an increased understanding of the impact of cultural differences on the effectiveness of suicide prevention strategies.
5.
Improve, expand and utilise translation services. Explore ways for all staff to have access to interpretation services, for example through mobile devices (in progress).
6.
Improve information sharing between prison and immigration removal centres. Key information (such as any vulnerabilities, history of violence, any mental health or clinical concerns) about the individual should be shared ahead of their arrival so that the immigration centre has …
7.
Develop and introduce a system with immigration centres that tracks any important dates or decisions that might be of importance to the detainee such as days leading up to deportation, around trials and / or appeals.
8.
Review and share learning and best practice on childhood and later trauma with aim of using it to prevent suicide and self-harm.
9.
Review and sharing of learning and best practice on how different organisations train staff, particularly on suicide and self-harm prevention.
10.
Ensure clear communication with detainees through information that is tailored to suit their unique needs and circumstances. Facilitate family contact where possible to provide support and mitigate feelings of hopelessness and uncertainty.
11.
Carry out further research to examine the impact of decreases to the immigration population, both in recent years and as part of the response to the Covid-19 pandemic, on self-harm rates and wider wellbeing indicators.
12.
Prioritise alternatives to detention for those with pre-existing or significant mental health needs (in progress).
13.
Carry out further research comparing remand, IPP prisoners and others serving indeterminate terms with those detained in IRCs to further understand the impact of uncertainty and hopelessness on detainees.
14.
Increase resources for Samaritans and listeners within IRCs.
15.
Ensure that vital information is shared between hospitals and immigration removal centres.
16.
Provide guidance to staff to enquire about the urgency of a matter which leads to a detainee requesting a healthcare appointment.
17.
Review healthcare screening processes to account for language barriers and the likelihood of limited prior interaction with healthcare systems and ensure that processes are understood and the detainee can participate.
18.
Work with HMPPS to update ACDT within removal centres (in progress).
19.
Develop and roll out cultural awareness training for staff to increase understanding of the different ways in which detainees might express pain or anxiety.
20.
Introduce the use of a checklist system or other cognitive aid that can be used by staff members during times of emergency to aid them to treat an individual humanely and effectively.
21.
Formalise mechanisms for sharing lessons learned across IRCs following a death and the involvement of independent scrutiny and facilitation at lessons learned exercises.
22.
Share regular updates of good practice with the different service providers encouraging them to share good practice with each centre. Good practice should be disseminated via regular newsletters or regular meetings with senior management of each centre. Devise formal ways …
23.
Work with the Ministry of Justice to allow non-relatives and relevant organisations to apply to be recognised as an interested person where family representation is not possible. Deliver improvements to information provided to bereaved families, including sources of specialist advice …
24.
Develop method of providing resources and feedback to bereaved families on actions taken and ensure these are subject to a regular review (in progress).
1 Oct 2020
Cross-cutting
Justice Select Committee inquiry on ‘the future of legal aid’
Consultation Response
Independent Advisory Panel on Deaths in Custody submission to the inquiry by the Justice Committee on the Future of Legal Aid – October 2020
29 Sep 2020
Prisons & Probation
Avoidable Natural Deaths in Prison Custody: Putting Things Right
Joint Report
Joint with Royal College of Nursing
15 recs
No formal response
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.
Government response summary
No formal government response published. Recommendations informed the IAPDC-HMPPS agreement on reducing and preventing deaths in prison (July 2023). The IAPDC states the 2020 recommendations "still stand" as of 2025, suggesting limited implementation.
15 recommendations
1.
Develop extended health information sharing, involving prisoners' families where possible, improving and sharing information in person escort records (PERS) and introducing prisoner 'medical passports' to facilitate a continuation of prescribing.
2.
Implement clinical coding systems across prison healthcare departments to ensure standardisation of reporting and data transfer.
3.
Implement a uniform comprehensive care pathway across prison healthcare that is evidence based and applies a joint approach across all agencies, departments and services.
4.
Implement the Quality Outcomes Framework (QOF) across the prison estate, including employing administrators to update records and make summaries and Code diagnoses.
5.
Overhaul secondary care referrals, including through developing: secondary care clinics in prisons in major specialities; an escort algorithm to prioritise outpatient visits and escorts; a contracted out service to conduct escorts as in the court service; a halt to, and …
6.
Conduct an in-depth review of the characteristics of natural deaths in women and BAME individuals and make specific amendments where appropriate.
7.
Develop a joint health and justice older persons strategy for the criminal justice system. This should be integrated with local social care plans and provision.
8.
Develop a dementia care pathway across the prison estate including making all prisons dementia friendly, with clear signage, well-lit areas preferably with as much natural light as possible, and consistently plain and levelled flooring.
9.
Reassess the policy on Do Not Resuscitate decisions and their use within the prison healthcare system to make clear at what time and in which situations it is appropriate to administer CPR.
10.
Review and overhaul the process of compassionate release from custody to make sure that it is clear, transparent, timely and fair.
11.
Review the application of the Care Act in prisons and for people on release from custody with a view to establishing minimum standards, sharing good practice and identifying poor or unacceptable performance under the Act.
12.
Implement the 'Dying Well in Custody' charter across prisons to maintain dignity, better support families and deliver uniform palliative care.
13.
Encourage student placements and rotational training schemes across disciplines. Streamline security clearance arrangements. Develop a forensic training academy and skills lab. Establish prison medicine as a sub-speciality.
14.
Convene regular standing meetings between the Prison and Probation Ombudsman, the office of the Chief Coroner, prison governors and healthcare managers to consider often repeated recommendations with solutions found and actioned. Create a national oversight mechanism to monitor deaths in …
15.
Improve standards of post-death investigations so that failures are identified and changes made. Ensure that non self-inflicted deaths are fully investigated by independent specialists.
1 Sep 2020
Cross-cutting
Home Affairs Select Committee inquiry on ‘black people, racism and human rights’
Consultation Response
Independent Advisory Panel on Deaths in Custody submission to the inquiry by the Joint Committee on Human Rights on black people, racism and human rights – September 2020
1 Sep 2020
Mental Health Act Detention
Centre for Mental Health’s review to guide the future of prison mental health care in England
Consultation Response
Independent Advisory Panel on Deaths in Custody submission to the Centre for Mental Health’s review to guide the future of prison mental health care in England.
28 Sep 2019
Prisons & Probation
A proposal for embedding staff and prisoner safety in all major decisions
Thematic Report
4 recs
Proposal for a Safety Assessment Board approach so that staff and prisoner safety is considered in all major operational and policy decisions affecting prisons. Contains 4 recommendations.
4 recommendations
1.
The department should develop a Safety Assessment to ensure that risks to staff and prisoner safety are fully considered before all relevant decisions.
2.
The department should work with the IAP to develop such an assessment.
3.
The department should, once implemented, monitor the process and improve it where necessary.
4.
The department should consider formalising this process in legislation in due course.
25 Jul 2019
Prisons & Probation
ONS: Drug-related deaths and suicide in prison custody in England and Wales 2008-2016
Statistical Analysis
The risk of suicide and drug-related deaths among prisoners, based on confidential matching of data from HM Prison and Probation Service and Office for National Statistics mortality records.
22 Jul 2019
Mental Health Act Detention
Sentencing Council’s consultation on sentencing offenders with mental health conditions or disorders
Consultation Response
Response to Sentencing Council: Overarching principles: Sentencing offenders with mental health conditions or disorders – Consultation
28 Jun 2019
Prisons & Probation
Intermediate sentences for public protection (IPPs): preventing self-harm and deaths in custody
Briefing Paper
15 recs
Briefing paper for ministers on Imprisonment for Public Protection (IPP) sentences and their association with self-harm and deaths in custody. Contains 15 recommendations.
15 recommendations
1.
The IAP remains convinced that Government should take legislative action to right the remaining injustice of the, now long-abolished, IPP sentence. There is an overarching need to review everyone still serving this sentence with a view to release and, at …
2.
Pending legislative change, IPP prisoners should receive a comprehensive review of their sentence and circumstances leading to a forward plan for each individual which should be updated regularly.
3.
This review must go beyond a paper-based process, and cover a range of issues relevant to the wellbeing of IPP prisoners such as (but not limited to): health (physical and mental, social care needs); daily/weekly activities/hours per week; work; education; …
4.
The roll-out across England of IPP progression panels, developed and piloted by HMPPS Wales, should be monitored to determine what works and to ensure closely integrated work between probation, prison, psychology, healthcare and safeguarding teams.
5.
A more therapeutic approach with structured opportunities to take personal responsibility and help others could be taken, using relevant learning from places such as HMP Warren Hill.
6.
Awareness among prison and probation staff of the potential risk factors and vulnerability of people serving an IPP sentence in prison and on release should be increased (particularly in the women’s estate); and emphasis placed on developing trusting professional relationships.
7.
A clinical review of modifiable risk factors and needs primarily in the area of mental health should be undertaken.
8.
This review should take into account the important social care and physical health needs that might increase risk of suicidality inside custody and on release.
9.
Where recommended, transfers to psychiatric care must be effected without delay.
10.
Increased support and ongoing health and social care services should be made available to people who have served an IPP sentence on release from custody. A specific stream of social prescribing could be developed for this group of people.
11.
In line with Lord Farmer’s reviews, support to maintain and facilitate family links through detention close to home, family visits or videolinks should be offered.
12.
Compassion should be shown to prisoners who have lost loved ones and bereavement or grief counselling offered.
13.
Following a death in custody respectful contact must be made and maintained, if wished, with the bereaved family. This would include keeping family members informed in a timely manner.
14.
Further research should be conducted to examine the link between self-inflicted deaths and the IPP sentence using different research designs.
15.
Recommendations from Prisons and Probation Ombudsman’s investigations and Coroners’ preventing future deaths reports following the deaths (both natural and self-inflicted) of IPP prisoners should be drawn together, considered thoroughly and implemented by health and justice services.
3 Jun 2019
Cross-cutting
Effective community sentences and the role treatment requirements can play in preventing deaths in custody
Joint Report
Joint with Magistrates Association
23 recs
Joint report with the Magistrates Association on how effective community sentences and treatment requirements can divert people from custody and reduce deaths. Contains 23 recommendations.
23 recommendations
1a.
The Ministry of Justice should ensure that forthcoming reforms to probation services include the requirement for local probation services to keep sentencers informed about community sentencing options in their local area. This could be achieved through information and presentations to …
1b.
A feedback mechanism for sentencers should be created for identification of areas where community sentencing options provided for in law are not made locally available in a timely way. Information gathered via this mechanism should be used to inform local …
1c.
A process whereby magistrates and district judges review the progress of individuals given treatment requirements should be developed; see 2g.
1d.
Magistrates and district judges should receive timely information from liaison and diversion services about a defendant’s mental health, learning disability, substance misuse and other needs; see recommendation 3.
1e.
The Judicial College should analyse whether current training on mental health conditions and disorders, including acquired brain injury, meets the needs of the judiciary and consider what further training may be required.
2a.
Following the five Community Sentence Treatment Requirement (CSTR) trial sites, the Ministry of Justice and Department of Health and Social Care should agree funding arrangements for national roll out of CSTRs. This should include universal and timely access to the …
2b.
A protocol for secondary care MHTRs should be developed and funding arrangements agreed by the Ministry of Justice and Department of Health and Social Care.
2c.
The overall funding necessary for treatment requirements should be reviewed by the Ministry of Justice and Department of Health and Social Care and made available, and the need to ring fence local funding considered.
2d.
The need for services for specific cohorts should be considered in the development and delivery of treatment requirements. Intersectionality should also be considered; for example, young men from Black and Minority Ethnic communities and women who have experienced abusive relationships …
2e.
Treatment requirements should be flexible and able to respond appropriately to offenders with multiple needs; for example, people with co-existing mental health and substance misuse problems.
2f.
Treatment requirements should be accessible for people with acquired brain injury, learning disabilities and/or autism and be flexible in responding to need.
2g.
The Ministry of Justice and Department of Health and Social Care should create a mechanism whereby treatment requirements are reviewed by magistrates. This would enable magistrates to monitor progress of how treatment requirements are delivered and of individual offenders (in …
3a.
Quarterly updates from liaison and diversion services should be provided to, amongst others, the Bench Chair and MA branch mental health and learning disability champion. The Bench Chair should ensure information is disseminated to all magistrates. Information provided by liaison …
3b.
A feedback loop between liaison and diversion services and members of the judiciary should be established to provide feedback on what is working well and where there are concerns so that early solutions can be found where difficulties arise.
3c.
Reports from liaison and diversion services should inform PSRs and be clearly referenced within the PSR as coming from liaison and diversion services; see recommendation 5c.
4a.
Over half of magistrates said they didn’t find Sentencing Council guidelines clear in setting out how they should take account of mental health needs. The two Sentencing Council consultations (Expanded Explanations in Sentencing Guidelines and Sentencing Offenders with Mental Health …
5a.
Relevant agencies should clarify when a pre-sentence report (PSR) is required and what information should be included. Written guidance should be issued, noting that sentencers should have full discretion to specify what information they want included in response to a …
5b.
Where a custodial sentence is being considered, the National Probation Service should ensure that PSRs address risk and vulnerability of the offender and whether a community sentence might offer improved justice and health outcomes.
5c.
Reports from liaison and diversion services should inform PSRs, and information provided by them should be clearly identified as such in the PSR. In the absence of information from liaison and diversion services, the case should either be adjourned until …
6a.
Access to secure and specialist beds, whether for assessment or treatment and care, should be dealt with in the same urgency for individuals in the criminal justice system as for those in the wider community. Prison should not be used …
6b.
Prison should never be used as a place of safety; this has implications for the Bail Act 1976 provision to remand a person into custody for their own protection25.
6c.
Should there be no alternative to a custodial sentence, reports by liaison and diversion services should be shared proportionately with the prison service and be available when the offender first arrives into prison.
6d.
The impact of the prison environment on prisoners’ mental health and wellbeing should be recognised. Prisoners should expect to be accommodated in an environment that promotes their mental health and wellbeing, and at the very least does no harm.
27 Feb 2019
Cross-cutting
Learning from bereaved families
Thematic Report
3 recs
Thematic paper on how the experiences and insight of bereaved families can improve investigations and help prevent future deaths in custody. Contains 3 recommendations.
3 recommendations
i.
The Ministerial Board should agree that the relevant agencies develop systems to involve families to a greater extent in the successful implementation of recommendations as part of the Ministerial Board’s work programme.
ii.
The Ministerial Board should agree that the systems mentioned in ‘i’ should be consistent with the set of principles outlined in this paper.
iii.
The Ministerial Board should agree that bereaved families should be consulted as a fundamental part of developing this work.
29 Nov 2018
Cross-cutting
Lord Farmer’s review of women in the criminal justice system
Consultation Response
Submission of evidence to Lord Farmer for his review of women in the criminal justice system and strengthening ties with their families
10 Oct 2018
Police Custody
Embedding recommendations to prevent deaths in custody
Thematic Report
Following the publication of the Angiolini Review into Deaths and Serious Incidents in Police Custody, the IAPDC submitted a paper to the Ministerial Board on Deaths in Custody to support and encourage effective learning after a death in custody.
22 Aug 2018
Mental Health Act Detention
Evidence to Sir Simon Wessley
Guidance
The IAPDC welcomed the substantive review of the Mental Health Act (1983), performed by Sir Simon Wessley. It contributed evidence to the second part of the review in August 2018.
31 May 2018
Cross-cutting
Mid-term report – May 2018
Chair's Report
Juliet Lyon, Chair of the Independent Advisory Panel on Deaths in Custody, mid-term report - May 2018
24 Feb 2018
Police Custody
Read the report: Alternatives to the use of restraint
Thematic Report
An initial review of the academic and operational literature regarding alternatives to the use of restraint in police custody.
1 Dec 2017
Prisons & Probation
Keeping safe – preventing suicide and self-harm in custody
Thematic Report
Keeping safe - preventing suicide and self-harm in custody. Prisoners' views collated by the IAP
29 May 2017
Prisons & Probation
Advice on self-inflicted deaths and self-harm at HMP Woodhill
Thematic Report
Independent professional advice on the prevention of self-inflicted deaths and self-harm at HMP Woodhill - report by Stephen Shaw
28 Mar 2017
Prisons & Probation
Preventing the Deaths of Women in Prison
Thematic Report
51 recs
Response May 2021
Examination of the factors contributing to deaths of women in prison, covering the journey from community through courts to custody. Contains 51 recommendations across pre-custody, reception, in-custody care, and system-wide reform.
Government response summary
All recommendations accepted by ministers. Implementation mapped into the Female Offender Strategy (June 2018). Prisons Minister Alex Chalk MP provided a detailed progress update (11 May 2021) covering: rollout of Offender Management in Custody (OMiC) keyworker scheme across women's estate; Women's Estate Self Harm Task Force (established April 2020) delivering trauma-informed initiatives, additional counselling, and women-specific training; revised ACCT v6 rolled out in female estate; renewed £500k Samaritans Listener scheme grant; Women's Estate Health and Social Care Review launched. However, Public Accounts Committee (2022) found only 31 of 65 Female Offender Strategy commitments fully achieved.
51 recommendations
1.
Ensure adequate information is provided to the courts including reports covering mental health need, vulnerability and safeguarding concerns.
2.
Encourage greater use of community sentences by the courts to include treatment orders.
3.
Coordinate national and local government leadership focus on prevention and the strategic reduction of women’s prison numbers.
4.
Roll-out liaison and diversion services across police stations and courts
5.
Increase investment in women’s services in the community and look to models of local authority pooled budgeting as in Greater Manchester.
6.
Develop a sustained network of women’s centres.
7.
Co-ordinate a multi-disciplinary response to vulnerable women involving family support and domestic violence services as well as health and justice provision.
8.
End delays in receiving prescribed medication on arrival and improve contact between GPs and prison healthcare.
9.
Improve arrangements for first night in custody.
10.
Conduct transfers in a longer-term planned manner, with more information provided to the women being moved.
11.
Improve drug and alcohol treatment in custody linked to treatment in the community.
12.
Encourage and support self-help groups and peer support, in particular sustaining a team of Samaritan Listeners and Insiders.
13.
Improve physical environment and remove ligature points from women’s cells/rooms.
14.
Ensure multi-disciplinary ACCT reviews, specifically including mental health staff.
15.
Provide mandatory mental health awareness training for staff and establish a system of staff support and supervision.
16.
Enable and support women to maintain family contact (see section on family contact).
17.
Focus the whole prison environment on promoting the mental and physical health and wellbeing of all prisoners in a trauma-informed way (see section on mental health).
18.
Develop a gender-aware and trauma-informed environment in all women’s prisons including staff training on the impact of separation and loss, and awareness of perinatal mental health and support for women at risk.
19.
Roll out higher level of emergency response training for all staff.
20.
Ensure every Mental Health Trust has a clinical lead for women’s mental health.
21.
Provide a greater range of mental health and substance misuse treatments, including the provision of counselling services and talking therapies, in the community.
22.
Provide counselling services to all women prisoners. Each women’s prison should employ a counsellor with placements for trainees routinely, and a national lead for counselling services should be instituted.
23.
Establish thorough-going mental health assessments for all within first 24 hours of arrival in custody.
24.
Review implementation of the Care Act 2014 which placed preventative duties on local authorities and required them to meet social care needs
25.
Ensure access to secure mental health accommodation is available in a timely manner to those who need it, prisons should not be used as places of safety.
26.
Ensure healthcare staff routinely share matters of risk of suicide with prison staff, in accordance with the IAP’s Information Sharing Statement.
27.
Develop a shared care plan for each woman to which she can contribute.
28.
Plan the transfers of women between prisons carefully with a standard form/template developed for handover and information regarding risk of suicide and self-harm.
29.
Ensure that women can retain their own information on transfer including their pin phone numbers.
30.
Learn and embed lessons set out by coroners, the Prison and Probation Ombudsman and the IPCC in improved transfer of information between agencies and establishments to keep women safe.
31.
Achieve compatibility between health information systems in England and Wales
32.
Put in place local information sharing protocols between all relevant health and justice, including liaison and diversion, services.
33.
Adopt nationally the updated Person Escort Record (PER) form with space to add information about risk as endorsed by the National Police Chief’s Council.
34.
Improve communication and information transfer between GP’s, midwives and prison healthcare.
35.
Improve communication between agencies during preparation for release.
36.
Impose community sentences, with family and domestic violence support where necessary, unless the offending is so serious or dangerous that only a custodial penalty will suffice.
37.
Create a custodial system closer to homes in smaller more residential accommodation linked to health and other local agencies.
38.
Implement in-cell telephones in all women’s prisons, and enable women to make free emergency telephone calls where necessary.
39.
Maximise family contact through better technology, to include use of videoconferencing and visiting arrangements.
40.
Consider and extend the use of release on temporary license (RoTL).
41.
Train and support staff for work with families and appoint family support/liaison officers in all establishments.
42.
Establish and maintain sustained partnerships with voluntary organisations offering family support.
43.
Provide and make accessible to women in prison the 24 hour Freephone, National Domestic Violence Hotline, run in partnership between Woman’s Aid and Refuge.
44.
Encourage family engagement in ACCT reviews.
45.
Ensure preparation for release is ongoing, forming part of a regularly reviewed sentence plan and engendering hope and a sense of future important to suicide prevention.
46.
Increase use of release on temporary license (ROTL) to enable women to resume contact with family and caring responsibilities and to undertake voluntary or paid work and training in the community.
47.
Oblige local authorities to provide safe housing for women prisoners who would otherwise become homeless at the point of release.
48.
Continue on release, if started in prison, mental healthcare and treatment for addictions.
49.
Provide social care support and mentoring on release for women with learning disabilities or learning difficulties.
50.
Review, and reinforce, compliance with Section 10 of the Offender Rehabilitation Act which requires commissioners and providers to take account of the particular needs of women in making supervision and rehabilitation arrangements.
51.
End recall to custody for most forms of technical breach of license and strengthen supervision arrangements instead.
1 Mar 2017
Prisons & Probation
Preventing the death of women in prison – March 2017
Thematic Report
This is a working document on preventing the death of women in prison from the Independent Advisory Panel on Deaths in Custody (IAP).
31 Aug 2016
Cross-cutting
End of term report – August 2016
Chair's Report
The Independent Advisory Panel on Deaths in Custody end of term report - August 2016
20 May 2016
Cross-cutting
Guidelines for the Management of Excited Delirium / Acute Behavioural Disturbance (May 2016)
Guidance
This document provides a guideline for Emergency Departments to safely and effectively manage adults who attend with Excited Delirium / Acute Behavioural Disturbance (ABD).
31 Mar 2015
Cross-cutting
End of term report – March 2015
Chair's Report
Lord Toby Harris, Chair of the Independent Advisory Panel on Deaths in Custody, end of term report - March 2015
29 Mar 2015
Mental Health Act Detention
Mental disorders and deaths in custody: Making the case for mental health literacy
External Research & Analysis
Mental disorders and deaths in custody: Making the case for mental health literacy -University of Greenwich & The Runnymede Trust
25 Jun 2013
Mental Health Act Detention
Analysis of Serious Untoward Incident Reports
External Research & Analysis
Examining a sample of 18 redacted Serious Untoward Incident reports following deaths of patients detained under the Mental Health Act.
1 Feb 2013
Cross-cutting
Family liaison common standards and principles
Guidance
The standards for family liaison services following a death in custody, which apply to organisations responsible for the care and treatment of the deceased (including secure settings that hold young people and children) as well as investigatory bodies.
11 Jan 2013
Police Custody
Common principles for safer restraint
Guidance
The Common Principles on the Safer Use of Restraint, published in 2013, were developed in conjunction with agencies representing Immigration, prisons, health, youth justice, police and the Restraint Advisory Board
1 Oct 2012
Cross-cutting
Deaths in Custody: The impact of Coroners’ Rule 43 reports on organisational learning
External Research & Analysis
Mendas Review: The impact of Coroners’ Rule 43 Reports on Organisational Learning
29 Feb 2012
Cross-cutting
End of term report – February 2012
Chair's Report
Lord Toby Harris, Chair of the Independent Advisory Panel on Deaths in Custody, end of term report February 2012