Skip to content
Font size:  

Deaths in Police custody – lessons from a ten-year review

30 June 2012 - Improvements in Police policies and practices have been reflected in better care of people in Police custody, as measured by the incidence of deaths of detainees studied in an independent review.

The Independent Police Conduct Authority has released a review of 27 deaths which occurred in Police custody. The review covered the ten years between 2000 and 2010 and was prompted by several deaths of heavily intoxicated detainees. It was also conducted in light of the Authority’s responsibilities under the United Nations Optional Protocol to the Convention against Torture.

The Authority Chair, Judge Sir David Carruthers, said deaths in custody are uncommon and do not necessarily reflect the quality of care generally provided by the Police.

“While it is rare in New Zealand for people to die while in Police custody, such deaths can be controversial. There may be issues around the use of force by Police during an arrest, or with the standard of care Police provide to a detainee. When a person dies while he or she is in custody, it has a serious impact on both their family and the Police officers involved. Public confidence in the Police may also be affected. While not all deaths in custody are foreseeable or preventable, in some cases the actions or omissions of Police staff may be a contributing factor,” Judge Carruthers said.

“The main purpose of the review was to examine the circumstances of each death and identify any recurring issues or developing trends. While the investigations into some deaths identified procedural omissions or errors, the purpose of the review is not to attribute blame; rather, to learn useful lessons from these cases.”

The effect of alcohol, drugs and mental health issues on people in Police custody, the training of custodial staff, and Police practices around restraint, searches and provision of medical treatment are identified as areas for further attention.

The Authority has made 20 recommendations. In making these recommendations, the Authority acknowledges the efforts made by Police in recent years to improve policies and procedures relating to the care of people in Police custody.

The review consisted of:

• the analysis of 27 deaths in or following Police custody which were referred to the Authority under section 13 of the Independent Police Conduct Authority Act 1988 during the 10-year period from 1 January 2000 to 1 January 2010;
• an assessment of New Zealand Police policies and procedures for managing people in custody; and
• consideration of international policies and research on deaths in Police custody.

A summary of findings and a list of recommendations follows.

Note: The term ‘death in custody’ refers to deaths which have occurred during arrest or detention by the Police. This includes situations where a person has died after becoming ill or injured while in custody and situations where a person has died while being transported to a mental health facility.

Police pursuits which result in death and shootings by Police were not included in the review, although they may have taken place in the process of an arrest.

This review considered a relatively small sample of 27 cases. The quantitative findings of the review may not be regarded as statistically significant. It is also difficult to identify meaningful trends from a small number of cases.  It is however possible to detect recurring issues and thus to consider whether Police policies, practices and procedures could be improved.

SUMMARY OF FINDINGS

Key findings of the review were that:

• All except one of the people who died while in Police custody were male, and almost half were Maori.
• The ages of the people who died ranged from 19 to 68 years.  The average age was 38.5 and the median 37.
• The most common cause of death was suicide by hanging, of which there were 10 cases (37%). However the number of suicides in custody has decreased in recent years.
• Seven (25.9%) of the deaths followed the use of restraint by Police during arrest, and seven (25.9%) were caused by the detainee’s medical condition. Three (11.1%) of the deaths were due to drug-related causes.
• Fourteen (51.9%) of the deaths involved people affected by mental health issues, including history of self-harm/suicide attempts, threats to commit suicide, depression, and schizophrenia.
• Thirteen (48.1%) of the people who died in Police custody were affected by alcohol at the time of their arrest, and nine (33.3%) were affected by drugs. Five of the 27 deaths (18.5%) involved people who were only in custody for the purposes of detoxification.
• Fifteen (55.6%) of the people who died in custody had been assessed as being at no risk, and eight (29.6%) had not undergone a formal risk evaluation.
• Four of the 27 deaths involved serious neglect of duty or breaches of policy by Police.

The recurring issues that emerged from the deaths in custody review include:

• the extent to which the detainees were affected by alcohol and drugs;
• the mental health of the detainees;
• Police methods of restraint and the danger of restraint asphyxia;
• problems with the searching, risk assessment and monitoring of detainees;
• the provision of medical treatment to detainees;
• handover procedures and the safety of Police cells; and
• the need for more extensive training of custody staff.

SUMMARY OF RECOMMENDATIONS

The Authority has recommended that the New Zealand Police:
1) work with the Ministry of Health and other appropriate stakeholders towards the establishment of detoxification centres or temporary shelters in order to provide appropriate medical care for heavily intoxicated persons;
2) ensure that the training provided to staff reinforces the dangers associated with restraining people in a prone position with their hands tied behind their back;
3) ensure that the training provided to staff reinforces the risks of positional asphyxia and other restraint-related medical conditions, and the appropriate tactical options for dealing with people who may be affected by these conditions;
4) amend the Custody/Charge Sheet to include a prompt to search the detainee and to record the outcome of the search;
5) amend the Managing Prisoners chapter of the Police Manual to direct that custody staff are required to record and explain any decision not to contact a family member or other appropriate person when they are going to release a detainee that has been found to be in need of care (and frequent or constant monitoring) while in custody;
6) provide custody staff with objective guidance (in the Managing Prisoners chapter of the Police Manual, the electronic custody module and the Custody/Charge Sheet) as to when a detainee should be assessed as being in need of care and frequent or constant monitoring;
7) amend the electronic custody module and the Custody/Charge Sheet to indicate that detainees who are unconscious or semi-conscious, unable to answer the risk assessment questions, and/or physically unable to look after themselves must be taken to hospital (as per the Managing Prisoners chapter of the Police Manual);
8) amend the risk evaluation in the electronic custody module and the Custody/Charge Sheet so that the questions relating to the medical condition of the detainee are grouped together (including questions about injury, illness or pain) and separated from the suicide risk indicators;
9) amend the risk evaluation in the electronic custody module and the Custody/Charge Sheet to include questions in respect of the level of consciousness of the detainee and the possible presence of a head injury;
10) provide custody staff with clearer guidelines in relation to the checking and rousing of detainees (particularly those under the influence of alcohol or drugs);
11) amend the Managing Prisoners chapter of the Police Manual to direct that custody staff are required to record and explain any decision not to contact a health professional for advice as to whether a detainee’s medication should be administered by a health professional;
12) amend the Managing Prisoners chapter of the Police Manual so that, in addition to being required to create NIA alerts when a detainee is known to have suicidal tendencies, custody staff are required to create a NIA alert when it is known that the detainee is a drug user or suffers from an ongoing medical condition;
13) develop a formal shift handover process in respect the care of detainees for inclusion in the Managing Prisoners chapter of the Police Manual;
14) continue to remove all potential hang points and CCTV blind spots, and to assess all Police cells, including holding cells and day rooms, for suicide risks;
15) amend the Managing Prisoners chapter of the Police Manual so it clearly states that detainees assessed to be in need of care and frequent or constant monitoring must be examined by a Police medical officer, DAO or CAT member;
16) amend the HSMP form so that it:
 - clearly states the requirement for custody staff to call a Police medical officer, DAO or CAT member to examine a detainee because he or she has been found to be in need of care and frequent or constant monitoring; and
 - includes a prompt for the custody officer to create a NIA alert when the detainee has been assessed to be in need of care while in custody; 
17) work with the Ministry of Health towards extending the watchhouse nurse programme so that custody staff nationwide have better access to medical advice for the care of detainees;
18) continue developing a national training module to meet the requirements of employees assigned to duties in the watch house, with particular emphasis on responsibilities for the evaluation of risk and the care and protection of persons in custody (as recommended by the Authority in its report on the death of Francisco Javier de Larratea Soler, published on 1 July 2011); 
19) resume working with the Authority towards the establishment of a framework for near miss reporting; and
20) engage with the Authority to develop an OPCAT awareness strategy and advance the agreed plan to develop an IPCA / Police OPCAT panel.  The OPCAT awareness strategy and joint panel will provide a platform for raising staff awareness about custodial issues and enable effective implementation of custody-related recommendations.

Acronym / Explanation

CAT Community Assessment Team (OR Community Assessment and Treatment Team OR Crisis Assessment Treatment Team
CCTV Closed-Circuit Television
DAO Duly Authorised Officer
HSMP Health and Safety Management Plan for a Person in Custody, used from March 2005
NIA National Intelligence Application, the New Zealand Police database
OPCAT Optional Protocol to the Convention Against Torture

 

 

 

 

Full report

Deaths in Custody - A Ten Year Review (PDF, 1.8 MB)

 

MoST Content Management V3.0.5306