Source · Deaths in custody oversight
Independent Advisory Panel on Deaths in Custody
Thematic reports, panel guidance, commissioned research and case investigations examining deaths and serious harm in state custody. Source: iapondeathsincustody.org.
115 reports
262 recommendations
3 with response
19 case investigations
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
Article 2 Investigation Report
Independent review of HMPPS internal investigation of allegations of unprofessional conduct - Dale Simon CBE
Article 2 Investigation Report
Report from the independent investigation into an incident of life-threatening self-harm involving ‘CR’
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.
Article 2 Investigation Report
Final report, article two compliant investigation in the case of 'DM'
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.
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
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.
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.
Article 2 Investigation Response
HMPPS response to Rob Allen report
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.
Article 2 Investigation Response
NHS England response to Rob Allen investigation report
Consultation Response
Submission of evidence to Lord Farmer for his review of women in the criminal justice system and strengthening ties with their families
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.
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.
Article 2 Investigation Response
HMPPS response to Mr Adakite investigation report recommendations.
Article 2 Investigation Report
Report of an investigation under Article 2 of the European Convention of Human Rights into the circumstances surrounding the life-threatening self-harm of Mr Everest.
Article 2 Investigation Response
Article 2 Investigation Response
HMPPS response to AC investigation report recommendations
Chair's Report
Juliet Lyon, Chair of the Independent Advisory Panel on Deaths in Custody, mid-term report - May 2018
Article 2 Investigation Report
Final Report of an Independent Investigation into the Case of AD commissioned by the Secretary of State for Justice in accordance with Article 2 of the European Convention on Human Rights
Article 2 Investigation Response
NHS England response to recommendations contained in a report of an independent investigation into the case of Mr Adakite
Article 2 Investigation Response
NHS England supplementary response to recommendations
Article 2 Investigation Response
NHS England response to Rob Allen investigation report – Appendix A - Liaison and Diversion Court Report – 2018
Article 2 Investigation Response
AC - response from NHS England to the report of an Independent investigation into the case of AC
Thematic Report
An initial review of the academic and operational literature regarding alternatives to the use of restraint in police custody.
Article 2 Investigation Response
HMPPS response to recommendations from the independent investigation in to the case of WA - (Please note, this is a scanned copy of a document)
Thematic Report
Keeping safe - preventing suicide and self-harm in custody. Prisoners' views collated by the IAP
Article 2 Investigation Response
WA - NHS England response to recommendations from the report of an investigation into the circumstances of an act of self harm by WA at HMP Ranby. (This is a scanned copy of a document)
Article 2 Investigation Report
Report of an Independent Investigation into the Case of Mr Adakite commissioned by the Secretary of State for Justice in accordance with Article 2 of the European Convention on Human Rights
Thematic Report
Independent professional advice on the prevention of self-inflicted deaths and self-harm at HMP Woodhill - report by Stephen Shaw
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 · Index 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.
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).
Chair's Report
The Independent Advisory Panel on Deaths in Custody end of term report - August 2016
Article 2 Investigation Report
Report of an investigation into the circumstances of an act of self-harm by WA at HMP Ranby commissioned by the Secretary of State for Justice in accordance with Article 2 of the European Convention on Human Rights
Guidance
This document provides a guideline for Emergency Departments to safely and effectively manage adults who attend with Excited Delirium / Acute Behavioural Disturbance (ABD).
Article 2 Investigation Report
Final Report of an Independent Investigation into the Case of Mr North commissioned by the Secretary of State for Justice in accordance with Article 2 of the European Convention on Human Rights
Article 2 Investigation Report
Report of an independent investigation into the case of AC commissioned by the Secretary of State for Justice in accordance with Article 2 of the European Convention on Human Rights
Chair's Report
Lord Toby Harris, Chair of the Independent Advisory Panel on Deaths in Custody, end of term report - March 2015
External Research & Analysis
Mental disorders and deaths in custody: Making the case for mental health literacy -University of Greenwich & The Runnymede Trust
Article 2 Investigation Response
NOMS reponse to Mr Quartz investigation report recommendations.
Article 2 Investigation Response
Mr Atlantic - response to recommendations
Article 2 Investigation Report
Final Report of an Investigation under Article 2 of the European Convention on Human Rights into the circumstances surrounding the attempted suicide of Mr Quartz at HM Prison Doncaster on 2 December 2008.
External Research & Analysis
Examining a sample of 18 redacted Serious Untoward Incident reports following deaths of patients detained under the Mental Health Act.
Article 2 Investigation Response
NOMS response to AB investigation report recommendations
Article 2 Investigation Report
Report of an independent investigation into the case of Mr Atlantic Commissioned by the Secretary of State for Justice in accordance with Article 2 of the European Convention on Human Rights.
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.
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
External Research & Analysis
Mendas Review: The impact of Coroners’ Rule 43 Reports on Organisational Learning
Chair's Report
Lord Toby Harris, Chair of the Independent Advisory Panel on Deaths in Custody, end of term report February 2012
Article 2 Investigation Response
NOMS response to JL investigation report
Publication coverage
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 |