Forum for Preventing
Deaths in Custody

ANNUAL
REPORT

2006-2007

1

Designed and printed
by the Independent
Police Complaints
Commission on
behalf of the Forum
for Preventing
Deaths in Custody

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Forum for Preventing
Deaths in Custody
Annual Report
2006-2007

The Forum’s
membership is
comprised of
representatives from
the following
organisations

Forum for Preventing
Deaths in Custody

• Association of Chief
Police Officers (ACPO)
• Border and
Immigration
Agency (BIA)
• Coroners’ Society
• Department of
Health
• Her Majesty’s
Inspectorate of
Constabulary (HMIC)

ANNUAL
REPORT

2006-2007

• Her Majesty’s
Inspectorate of
Prisons (HMCIP)
• Her Majesty’s Prison
Service (HMPS)
• Home Office,
Policing Powers and
Protection Unit
• Independent Police
Complaints
Commission (IPCC)
• INQUEST
• Mental Health Act
Commission (MHAC)
• National Offender
Management Service
(NOMS)
• National Probation
Directorate (NPD)
• Prisons and Probation
Ombudsman (PPO)
• Youth Justice
Board (YJB)

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Contents

Chair’s Foreword

5

Executive Summary

8

What is the Forum?
Terms of Reference

10

The Scope of the Forum

10

Background to the Forum’s development

10

More recent developments

12

What have we achieved this year?
Roundtable learning from deaths

14

Better access to information

16

Working groups

17

Coroners reform

19

Spreading knowledge about deaths

20

The Forum’s website

21

The Government response to the
Joint Committee on Human Rights’ 2006 letter

22

Collaborative working

22

Links across the UK

22

Improving inter-agency working

23

Future goals for the Forum

24

Annexes
Annex 1: How many people die in custody in England and Wales

25

Annex 2: The Forum’s letter to Rt Hon Harriet Harman MP, 4 August 2006

29

Annex 3: Discussion paper: Strengthening the Forum for
Preventing Deaths in Custody

31

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Chair’s
Foreword

The commitment to the Forum by those that have the responsibility for detaining and
caring for those in custody, has been crucial to our work this year. The Forum’s
membership provides a strong foundation of expertise and experience and we have
started the process of sharing information and experiences and drawing up lessons that
we hope will make a difference. It is therefore only fitting that I open this annual report
with a thank you to the Forum’s fifteen member organisations. Their willingness to
share openly information has been critical, as has their energy for our work and
commitment that the Forum should make a real difference to reduce custody deaths.
However, it is important to note that, while this report reflects the views of the majority
of the Forum’s members, there are inevitably differences of opinion over certain issues.
I am grateful to each of the members for their contributions to this report, but
emphasise that it is published in my name and that of the secretary.
This is the Forum’s first annual report, and in practice it covers the work we have
undertaken in our first eighteen months. We have now held five full meetings and have
had a full time secretary for a year. We have already explored some of the key issues
pertinent to preventing deaths in custody. Member organisations have considered a
great deal of information about how individually they are working to reduce the
number of deaths in prisons, police and mental health settings and elsewhere. We have
also started to explore the need for similar work both in Scotland and in Northern
Ireland although so far the Forum’s resources have restricted us to primarily working in
England and Wales. Interestingly the concept of a body to learn lessons and to try to
prevent deaths in custody across the different institutions seems to have occurred first
here and we are yet to find any parallel anywhere else in the world. Coroners in Australia
though seem to be further ahead of their colleagues in the UK in trying to ensure that
lessons are learnt from all deaths (not just those that occur in custody).
We have already seen much evidence of good practice in different custodial settings in
England and Wales. A key area of work has been examining how each of the
organisations shares and learns lessons about deaths in custody both internally and
with other sectors. However, we have found weaknesses in some of the systems and we
know that more could be done to prevent deaths in custody and it is this that spurs the

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members of the Forum to further action. Concern about the ability and willingness to
learn from inquests led us to seek changes to the powers available to coroners in
preventing future deaths. We believe that the Coroner Reform Bill will be a step towards
much needed improvement to the coronial system and it is very unfortunate that the
legislation has not already been implemented. However until the Bill is formally
introduced we recommend improvements to the system and are seeking to achieve
these through amendments to the Coroners Rules.
Although we have achieved much in eighteen months, we are still in the first stages of
our development. On 16 May 2007 the Government made a commitment to reviewing
and strengthening the Forum’s current arrangements; something which we very much
welcome. Lack of resources has made our task a difficult one. We have not been able to
conduct or commission research into any of the issues we believe are worthy of it, and
we have no capacity to monitor or report on the recommendations that may be made
as a result of investigations, inspections or inquests. However, the Home Office (and in
more recent months the Ministry of Justice) through the National Offender
Management Service, has provided the resources for an independent Secretary to the
Forum, Kate Eves. I am particularly grateful for all her efforts to develop the Forum,
despite the lack of resources to do so. Ms Eves is seconded to the Forum from the Prisons
and Probation Ombudsman’s Office. I am grateful to Stephen Shaw, who holds that
office, for releasing an experienced member of his staff for this purpose.
In the absence of a fully-funded secretariat I have been grateful for the opportunity to
form links with other groups performing similar roles to our own. The Forum has
developed direct links with the Ministerial Roundtable on Suicides in Prison and the
Department of Health’s Suicide Prevention Strategy Group. I, and the other Forum
members, have very much welcomed the involvement of Baroness Stern, who attends
the Forum meetings as an observer from the Joint Committee on Human Rights. We
have also been encouraged by Baroness Scotland hosting an event to bring together
organisations working in this important area.
I also owe thanks to INQUEST whose committment and contribution have been
particularly welcome, especially given that they are a small, non-governmental
organisation with limited resources.
This report is a welcome opportunity to reflect on what we have achieved in our first
eighteen months; it is also an opportunity for us to acknowledge that too many people
continue to die in custody and that some of those deaths could have been prevented.
That remains a real and urgent challenge. We hope that the Government’s review
will recognise that the Forum must have the autonomy and resources to act when it
feels it necessary. The Forum is succeeding in bringing together members with
expertise in preventing custody deaths but our ability to do more than this is limited at
the moment.
At my suggestion, the Forum has agreed that the chair of the Forum should be
completely independent of those involved in the business of detention and independent
even of those whose job it is to oversee those functions.
Personally, I believe it was unfortunate that the Government resisted the extension of
the Corporate Manslaughter Bill to deaths in custody and I am grateful that members of

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the House of Lords persuaded the Government to change its mind. Although I expect
there to be few convictions in this respect, I believe that it is likely to make a difference
to how those in charge of custodial institutions understand their responsibilities.
However, individual members of the Forum have different views on the inclusion of
custody deaths in this legislation and the Forum has therefore not taken an official view.
Despite the differing perspectives of member organisations, the Forum will continue to
monitor the development of the Corporate Manslaughter Act with interest.
I believe that one of the most significant contributions this report makes is to show
that approximately 600 people die in custody each year, with about a third of these
apparently from other than natural causes. While it is not possible to eliminate every
one of those deaths, it is clear that many lives could and should have been saved.
Many of the subjects we have examined provide significant challenges for the
organisations involved in the Forum. For example, we have explored the management
of detainees who are difficult to manage but still need to be protected and cared for.
Throughout our exchanges, the agencies with an oversight or investigative function
have been able to raise concerns about deaths which have occurred as a result of poor
policy or practice. But we have equally been able to share examples of situations in
which staff deal extremely well with people with very complex needs. Sharing the
learning that results from both circumstances has been moving, rewarding and an
impetus towards improvement. I commend this first annual report.
John Wadham
Chair
Forum for Preventing Deaths in Custody

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Executive
Summary

1. Almost 600 1 people die in custody each year. Many of these deaths are through
natural causes but a great many others are as a result of apparent suicide attempts
and other non natural causes. This report is a welcome opportunity to reflect on
what the Forum has achieved in our first eighteen months but it is also an important
opportunity for us to acknowledge that too many people continue to die in custody
and that some of those deaths could have been prevented.
2. The concept of a body to learn lessons and to try to prevent deaths in custody across
the different institutions seems to have occurred first here in England and Wales: we
are yet to find any parallel to the Forum anywhere else in the world. However, some
other jurisdictions are further ahead of their colleagues in the UK in trying to ensure
that lessons are learnt from all deaths (not just those that occur in custody);
coroners in Australia have made a great deal more progress than is the case in the
UK. Concern about the ability and willingness to learn from inquests led us to seek
changes to the powers available to coroners in preventing future deaths. We believe
that the Coroner Reform Bill will be a step towards much needed improvement to
the coronial system.
3. We have already seen much evidence of good practice in different custodial settings
in England and Wales. An example of this is the fact that there has not been a
restraint related death in the Prison Service for 12 years. A key area of work for the
Forum is examining how each of the organisations learns lessons from previous
deaths and shares this learning both internally and with other sectors.
4. The Forum is still in the first stages of its development. On 16 May 2007 the
Government made a commitment to review the Forum’s current arrangements with
a view to strengthening them. The Forum very much welcomes this review as the
current lack of resources has made the group’s task a difficult one. The Forum has
not been able to conduct or commission research into any of the issues we believe
are worthy of it, and we have no capacity to monitor or report on the
recommendations that may be made as a result of investigations, inspections or
inquests. The Forum believes that its chair should be completely independent of the
member organisations.
5. The Forum’s work over its first eighteen months has demonstrated the need for a
more robust and joined-up approach to information sharing between agencies. An
example of this is the use of the Prisoner Escort Record (known as a PER form). The
PER form is used to record information about people in custody, and can often be the
only way of transferring information about risk of self-harm or vulnerability from
one agency to another. The Forum advocates a more joined-up approach between
the Prison Service and police. The PER form needs to be developed to reflect the
1 This figure includes all recorded deaths of patients detained under the Mental Health Act 1983, all deaths of residents of approved
premises and all deaths in prison, immigration and juvenile custody. It also includes all deaths in or following police custody but does not
include all deaths of those who have recently been discharged from hospital, immigration detention or released from prison custody.

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needs of both agencies so that it can offer the best possible protection for those in
their charge.
6. The Forum’s work is also prompting further consultation between the police and
Prison Service on ensuring that the Police National Computer (PNC) is available to
prison staff. It is the Forum’s view that access to the PNC by prison staff would help
them to make better risk assessments. In addition, by allowing the Prison Service to
enter data, the police would also be more aware of safety issues when the person
concerned is next dealt with by police officers. Discussions to date have shown that
the two bodies have had different expectations about how and when this can
be progressed. The Forum expects to continue its focus on this issue during the
coming year.
7. The Forum has set up Working Groups to look at our areas of concern in more detail.
We recently published the report of the Working Group on the Physical Environment.
This report explored how the risk of suicide and self harm can be reduced by the
appropriate design, management and layout of the custody environment. The
group’s work highlighted how much technical information, expertise and experience
exists within the different sectors and recommended the establishment of a
database to distil all of this valuable information.

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What is the
Forum?

The Forum’s terms of reference
“The Forum exists to effect real change to prevent deaths
in custody.”

The scope of the Forum
The aim of the Forum is to increase learning
opportunities. Initially the Forum will cover areas of work
that fall within the responsibility of the Home Office,
Ministry of Justice and Department of Health. In practice,
this will mean work around deaths of people detained in
police custody, prison, approved premises, immigration
custody or those detained under the Mental Health Act.
Deaths which occur after prison release may also be
included in the Forum’s scope, as may ‘near deaths’, both
of which can provide important sources of learning.

The background to the Forum’s
development
There have been proposals to set up some kind of body to
oversee and monitor deaths in custody for many years
and the chief advocate for these has been the
organisation INQUEST. In March 2003 Liberty published
its report on ‘Deaths in Custody: Redress and Remedies’ in
collaboration with others, including INQUEST.
Liberty’s report emphasised its support for the
creation of:
“a separate, over-arching Standing Commission on
Custody Deaths. Its mandate should be to bring
together the experiences from the separate
investigatory bodies set up to deal with police,
prison, hospital deaths and others. Such an overarching body could identify key issues and
problems, develop common programmes, research
and disseminate findings where appropriate, and
ensure services work together for change. Lessons
learned in one institution could be promoted in
other institutions, best practice could be
promoted, and new policies designed to prevent
deaths could be drafted and implemented across

The membership of the
Forum consists of senior
representatives from
each of the following:
• Association of Chief
Police Officers (ACPO)
• Border and
Immigration
Agency (BIA)
• Coroners’ Society
• Department of
Health
• Her Majesty’s
Inspectorate of
Constabulary (HMIC)
• Her Majesty’s
Inspectorate of
Prisons (HMCIP)
• Her Majesty’s Prison
Service (HMPS)
• Home Office,
Policing Powers and
Protection Unit
• Independent Police
Complaints
Commission (IPCC)
• INQUEST
• Mental Health Act
Commission (MHAC)
• National Offender
Management Service
(NOMS)
• National Probation
Directorate (NPD)
• Prisons and
Probation
Ombudsman (PPO)
• Youth Justice
Board (YJB)

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all institutions. Differing policies could be identified and changes suggested (for
example with regard to restraint techniques, where it appears that every
institution has different policies).”
In July 2003, the Joint Committee on Human Rights (JCHR), made up of Peers and MPs,
launched an inquiry into deaths in custody and many of the Forum’s members, including
INQUEST, gave evidence.
In its 2003 submission to the JCHR, INQUEST advocated setting up a completely separate
commission to investigate all forms of deaths in institutions. The submission said:
“Many of the issues arising from deaths in custody need to be fed into the wider
agenda for social inclusion of goverment, local authorities and the voluntary
sector. Many of the deaths which occur are part of a pattern which impacts on
policies on combating racism, drug and alcohol use, homelessness, mental
health, crime prevention and policing.
“To this end we recommend the setting up of a Standing Commission on
Custodial Deaths which would bring together the experiences from the separate
investigation bodies set up to deal with the police, prisons, hospital deaths and
others. Such an over-arching body could identify key issues and problems arising
out of the investigation and inquest process following deaths and it would
monitor the outcomes and progress of any recommendations. It could also look
at serious incidents of self harm and near deaths in custody where there is a need
to review and identify any lessons. Arising from this it would develop policy and
research, disseminate findings where appropriate and collaborate working.
Lessons learnt in one institution could be promoted in other institutions, best
practice could be promoted and new policies designed to prevent deaths could be
drafted and implemented across all the institutions. It would play a key role in
the promotion of the culture of human rights in regard to the protection of
people in custody.
“It should also have the powers to hold a wider inquiry where it sees a consistent
pattern of deaths. Such an inquiry could give voice to and a platform for
examination of those broader thematic issues and those issues of democratic
accountability, democratic control and redress over systematic management
failings that fall outside the scope of the inquest. One of its functions would also
be to lay the past to rest and assisting the process of effecting real and
meaningful change.”
The JCHR published its report on deaths in custody in December 2004. Amongst other
things, the committee recommended that the Home Office and Department of Health
should establish a cross Government expert task force on deaths in custody. As a
consequence, in July 2004, the Independent Police Complaints Commission (IPCC) had
separately suggested the idea of a Forum to capture cross sector learning following
deaths in custody. The proposal met with a positive response from custodians and
investigators involved in the area of work. Meetings in March and June 2005 brought
together key organisations such as the Prisons and Probation Ombudsman’s Office and

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HM Inspectorate of Prisons. It was quickly established that much could be learned by
agencies sharing information and learning across institutions.
In October 2005, the Government responded to the JCHR’s report by outlining its
commitment to better co-ordinate the existing processes and to work with the key
agencies to consolidate a new multi-agency forum to take this forward. The Forum met
for the first time in November 2005 and, following work to draft their terms of
reference, met again in February 2006 to agree the programme of work for the coming
year. Subsequently, the Forum has held four further meetings in June and October 2006
and February and June 2007.

More recent developments
In December 2006, the Joint Committee wrote to the Government seeking an update on
the Forum’s work. The Forum’s chair contributed an account of the work that the group
had undertaken so far. On 16 May 2007 the Government announced a commitment to
strengthen the Forum and is currently conducting a review of the current arrangements.
The review is due to report in November 2007.

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What have
we achieved
this year?

Our agenda to date has been ambitious. A key task for the Forum’s tri-annual meetings
is establishing how sources of learning could be better shared. We were surprised how
little sharing of problems and solutions there had been to date, but how interested
people were in trying to find the solutions and the common threads. We have explored
how the member organisations learn from deaths and share information and how
recommendations from inspections, investigations and inquests are handled. Our
October 2006 meeting focused on how prisoners and detainees are managed. Our
discussion included, but was not limited to, the use of control and restraint,
segregation/ seclusion and alternative methods of managing difficult and violent
prisoners. In February 2007, we explored how staff are trained to prevent deaths in the
different custody environments. Our June 2007 meeting examined the issues specific to
women in custody and was informed by the recent publication of the Corston Report: A
Review of Women with Particular Vulnerabilities in the Criminal Justice System. (The
report can be accessed at the Home Office website:
www.homeoffice.gov.uk/documents/corston-report/corston-pt-1?view=Binary)

Case Study: Learning Lessons from Deaths in Prison Segregation
• Between April 2004 and March 2007 there were 33 deaths in segregation units. Of
those deaths 31 were apparently self inflicted. The vast majority of those who died
in prison segregation were men (only two of the 33 were women).
• Overall, deaths in segregation units have accounted for 13% of all prison
self- inflicted deaths between April 2004 and March 2007. The figure was 20% in
2004-2005; 8% in 2005-2006 and 11% in 2006-2007.
• The prisoners who are the most ‘difficult’ are often also the most vulnerable. Very
damaged people can also be very damaging to others. Staff are undoubtedly faced
with difficult decisions as to where to hold some prisoners. Prisoners may end up in
segregation units when all other options have been exhausted. However, there have
been examples where alternative options to segregation have not been adequately
explored.
• The effect of segregation on an already vulnerable person’s state of mind can be
severe. There have been instances of failure to implement safety mechanisms
particularly for prisoners at risk of self harm. For some of those prisoners who have
died in segregation, the required case conferences and mental health assessments
appear not to have taken place.
• The importance of safety algorithms and safeguarding those who are mentally ill
cannot be underestimated. We have seen examples of an over-reliance on
healthcare staff making decisions, and inconsistencies in the quality of the
completion of safety algorithms (such as failing to consult medical notes).

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Case Study: Learning Lessons from Deaths in Prison Segregation (continued)
• In addition to the effects of segregation itself, the impact of restricted access to
stimulus and a restricted regime can also be severe. There have been examples of
prisoners subject to impoverished regimes without television, radio, reading
materials, in-cell hobbies or any other occupation. Giving vulnerable prisoners
something to occupy their time is likely to be a crucial part of safeguarding the
welfare of those in segregation.
• The Forum welcomes work being undertaken jointly by the Prison Service Safer
Custody Group and the Department of Health to improve the safety and health of
prisoners held in segregation settings. This work aims to ensure that prisoners
being held in segregation have the same access to the same range of high quality
health and mental health services as those living in the community and to prevent
and/or reduce the number of prisoners who are physically/mentally ill or
vulnerable to suicide/self-harm held in segregated settings.

Roundtable learning from deaths
Reduction in restraint deaths in prisons
Following a number of restraint related deaths in the early 1990s, the Prison Service has
worked hard to change its approach to Control and Restraint (the practice of retraining
face down was identified as particularly risky). We recognise that the Prison Service has
taken steps to learn from these earlier deaths, as is demonstrated by the fact that there
have been no restraint related deaths in prison since 1995. The Forum wants to ensure
that the lessons learned by the Prison Service are communicated to other sectors. We
recognise that, on occasion, police custody death during or following restraint can be
very complex as they potentially involve aggrevating factors such as drug swallowing or
intoxication.

Difficulty in identifying those who are presenting
an immediate risk of harming themselves
Staff who are regularly exposed to highly vulnerable and suicidal individuals often need
training in when to ask probing questions. There is a risk that constant exposure to
people who express the desire to harm themselves and others can result in complacency
when there is a real risk of them acting out this behaviour. We have heard of many
individuals who appeared “okay on the day” who have gone on to take their own lives.
All too often those who have made the decision to end their lives are calmer in the time
between that decision and when they actually take steps to carry this out.
Investigations into deaths in custody should achieve many things - not least providing
families with an insight into what has happened and fulfilling obligations under Article
2 of the European Convention on Human Rights (ECHR). However, investigations should
also be instrumental in helping staff to learn from particular experiences and to gain or
recover confidence in working with vulnerable patients or detainees.
Training and support for staff who deal with very violent and vulnerable detainees or
patients is crucial. We have heard reports of staff dealing with very violent individuals
who are in seclusion in hospital settings where there has been evidence of staff being
frightened to carry out the necessary checks. Staff need to be equipped to care for
vulnerable and violent patients in a way that enables them to protect themselves.

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How can we make sure that individuals are placed
in the most suitable environment?
We have heard numerous examples of vulnerable individuals being placed into
environments which are not equipped to care for them. In some cases care that was
provided in the community has ceased once the person is in custody, despite the
Department of Health’s responsibility to provide continuity of care for those who were
receiving treatment in the community. These examples have not just related to
individuals whose mental health is poor. People whose physical illnesses make custody
inappropriate are also held in conditions that cannot meet their needs.

The risks associated with new types of sentencing, pressures and priorities
It is well documented that uncertainty can make prisoners particularly vulnerable.
Those who have received an Indeterminate Public Protection (IPP) sentence may be
particularly at risk, especially as there are signs that both prison staff and prisoners are
unclear what the sentence means in practice. The Prison Service has significant
difficulties in ‘processing’ IPP prisoners on this type of sentence through the system,
with prisoners backing up in local prisons awaiting transfer to first stage lifer centres.
In addition to IPP sentences, being recalled to prison having had a licence revoked could
cause particular risks, and the prisoner could find themselves ‘fast-tracked’ through
induction, potentially increasing their vulnerability. The uncertainly of their situation,
coupled with an increasing presumption towards deportation, may mean that foreign
nationals are disproportionately at risk of suicide or self harm. On occasions language
barriers may make it difficult to communicate.

Failures to treat alcoholism with sufficient seriousness
We are concerned that alcohol intoxication and addiction amongst detainees is not
always taken sufficiently seriously. There have been instances when medication has not
been appropriately dispensed. Lessons also need to be learned from deaths where front
line staff appear to have become desensitised to the risks associated with extreme
intoxication. It is crucial that staff are trained and refreshed to identify risk factors. They
may also need to be reminded of the importance of making commonsense decisions
about when it is not appropriate to care for someone in a custody environment. While
there have been examples where ambulance services have refused to attend to
individuals, there are also examples of good practice with ambulance trusts piloting
ways to work with the local police force.

Failure to learn from near deaths
A primary barrier to learning lessons is the lack of robust structures for collating and
disseminating information. This may particularly be the case for incidents that do not
result in a death and are therefore not exposed to an investigation or inquest
proceedings. The Forum will take a particular interest in two Article 2 compliant
investigations (one into a near death, one into repeat self-harm) that are being
conducted by the Prisons and Probation Ombudsman (PPO).

Systems to investigate deaths and learn lessons
The systems to investigate deaths in custody vary between the sectors represented on
the Forum. If we are to learn lessons and to reduce or prevent deaths in custody, the
systems for investigation must be sufficient to carry out their tasks. We welcome the

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Government’s commitment to put the Prisons and Probation Ombudsman on a
statutory footing and to confirm that office with the powers it needs to carry out its
functions (and to comply with the strictures of Article 2 of the European Convention on
Human Rights).
However, the Forum is aware that the system for investigating the deaths of patients
who have been detained in hospital under the Mental Health Act 1983 differs
significantly from that in respect of deaths in police or prison custody. The Forum will
wish to consider the effectiveness and independence of the mental health investigation
system in the coming year.
Forum members have also raised concerns regarding the time taken to complete
investigations and inquests into custody deaths; this is something which inhibits
effectve learning.
This list is by no means exhaustive. The Forum has also discussed a number of other lessons
that arise from deaths in custody including the importance of robust support mechanisms
for detainees during the early days in custody and the particular vulnerabilities of
detainees who are withdrawing from or being maintained on drugs.

Better access to information
The early stages of setting up the Forum have revealed that there is a great deal of
information about custody deaths available. However, much of the basic statistical
information is not readily accessible. The Forum is in an ideal position to collate and
share such information and this report provides some key information which, to date,
does not appear to be available from other sources.

How many people die in custody in England and Wales?
2004/05

2005/06

2006/07

Police

36

28

Data not available
at time of publication

Prison

199

164

162

Patients detained under
the Mental Health Act
1983

328

373

351

Immigration Detention

4

3

0

20

17

10

Youth Custody

3

1

0

TOTAL

590

586

5233

Approved

Premises2

NOTE: It is important to note that there are varying practices in how data are collated and analysed between
each of the organisations represented at the Forum. For this reason, the data shown in the above table include
deaths in custody of all classification (including apparently self inflicted, homicide and natural causes) and gives
no indication of age, gender or race of the person who died. For more detailed information about the
classification of deaths in each type of custody please see Annex 1.
2 Statistics for deaths of Approved Premises Residents have been provided for calendar years rather than financial reporting years so

these statistics are for the calendar years 2004, 2005 and 2006 respectively.
3 Excluding deaths in or following police custody during 2006/2007

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Working groups
Physical custody environments
With a record prison population and the construction of larger police custody suites, the
physical environment into which detained persons are received and cared for is under
pressure. The Forum provides an opportunity to share expertise and knowledge across
the sectors. Member organisations employ a range of approaches to reduce harm by
changing the physical environment. The Forum has set up a working group to examine
different approaches to the design, management and maintenance of custody
environments. The group is examining all aspects of ‘technical’ and design-based
approaches to harm prevention (including the removal of ligature points, the location or
layout of cell/ ward and the use of CCTV). The working group has produced a report to
summarise the approaches being taken by each of the sectors with regard to the
physical custody environment. The report aims to identify gaps in knowledge, practice
or policy, and also highlights good practice and how this might be shared. A summary
of the report’s recommendation is reproduced below:
1 Ensuring that the environment is appropriate
• In some parts of the prison estate, being placed in a Safer Cell can have a
stigmatising effect. While Safer Cells are, understandably, often located in the high
risk areas within prisons, consideration needs to be given to placing the cells
amongst standard cells. This, coupled with the appropriate management of at risk
prisoners, is conducive to reducing stigma and normalising the environment of
those who may be vulnerable to self harm.
• The Working Group welcomed the joint Department of Health and Royal College of
Psychiatrists’ review of Core Standards of Safety. The Group recommended that,
following publication of the review, the Forum should seek advice from its authors
on how the standards will be implemented.
• In their 1998 report entitled Not just Bricks and Mortar, the Royal College of
Psychiatrists recommended that clinicians should involve themselves early on in the
project when mental health wards are being designed and planned. This is often
now the norm in new mental health builds. Indeed, in many new mental health
builds, patients’ input is also a very important part of the design process. The group
considered that the importance of close liaison between practitioners and
designers/ architects and manufacturers cannot be over stated. As new facilities
are developed it is crucial to reflect on the lessons that have been learned from past
experiences and practitioners are the people best placed to provide this insight.
2 Appropriate maintenance and upkeep of the built environment
• It is crucial that Safer Cells are properly maintained. Historically, prison managers
have been reluctant to afford Safer Cells the level of monitoring and maintenance
that they require, viewing them as somehow separate to the rest of the prison’s
accommodation. Governors must take responsibility for their Safer Cells ensuring
that a maintenance protocol is in place between management and ‘works’ staff
which adheres to the specific requirements of Safer Cells.
• The Working Group acknowledged that there is a lack of commitment to timely and
comprehensive maintenance of units. A lack of full maintenance agreements and

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protected maintenance budgets allows maintenance budgets to be squeezed to
accommodate other priorities.
• Individuals who are responsible for the repairs and upkeep are not always
sufficiently in tune with the safety implications of certain actions or inactions.
There is a need for greater cohesion between the criminal justice inspectors and
those who have responsibility for the ‘fabric’ of the cells.
3 Improving learning from ‘near deaths’ and increasing the sharing of information on
new and emerging risks from physical environments
• Anecdotally, the physical environment of custodial settings are given a lower
priority as part of investigations into deaths than are the actions of staff.
Organisations need to be aware of this and to ensure that the lessons are not being
missed.
• The Group found that opportunities do exist for greater learning from deaths and
adverse incidents in custody; however, this is currently dependent on the
establishment of a robust reporting and dissemination process. The Forum could
play a crucial role in sharing these lessons beyond the individual service to other
custodial sectors.
• Ligature points can be found at any height. Simple lessons such as this, shared
quickly and across a broad range of sectors, can save lives.
• Detainees can demonstrate ingenuity when presented with seemingly safe
surroundings. The Working Group discussed a recent incident in a police cell where
the metal tag from an exposed water pipe had been removed by a detainee; the tag
was sharp and could easily be used for self harm or as a weapon against another
person. Dissemination of this information across other forces revealed that this was
not an isolated incident. The Group considered that communication and
information sharing is key. The Forum should consider what contribution it should
make to facilitating cross-sector information sharing specifically in this area.

4 Addressing discrepancies in the standards of safety in the built environment
• Responsibility for the procurement of building materials and equipment in police
forces falls to individual Chief Officers. Suitable materials and equipment can be
developed at less prohibitively expensive rates if practitioners and manufacturers
are able to engage in consultation at an early stage. Not only would this approach
yield financial savings, but would potentially provide products that are suitable for
purpose from the outset.
• The new, larger police custody facilities currently being built will present different
challenges for the staff that manage and work in them. The working group
emphasised the need for practitioners to be heavily involved with the design of
these facilities. Chief Officers must review staffing levels on commissioning a new
or rebuilt custody facility to ensure that they are adequate. New custody facilities
often require new working arrangements.

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• The Working Group welcomed the Youth Justice Board’s (YJB) review of its
Safeguards Programmes and suggested that the Forum invite the YJB to report on
the findings of its review at the end of 2007.

Family liaison
The Forum has been instrumental in bringing together representatives from several
organisations with an interest in death in custody issues from a family perspective. It is
envisaged that the group will be able to offer a family perspective on issues raised and
proposals made by the Forum. In addition, we hope that the representatives will be able
to work together to share best practice and to create a more co-ordinated approach to
reduce the confusion that is often experienced by bereaved families. This group should
also be able to offer an invaluable peer support mechanism for those who work closely
with families.
Aside from our work with agencies who link with bereaved families, the Forum
recognises the need to to engage directly with families affected by custody deaths. The
perspectives and experiences of those families (and the groups that represent them) are
diverse and it is essential that we find the best way of working with them. This work is
a priority for the Forum and will continue to be over the coming months.
We are also setting up working groups to look specifically at the particular risks relating
to the transfer and escorting of detainees and the training given to escort staff.

Coroners Reform
The members of the Forum welcomed the Coroner Reform Bill, and its publication
informed our discussions about the essential role that coroners can play in preventing
future deaths in custody. In August 2006 we wrote to the Rt Hon Harriet Harman QC
MP, then Minister of State for Constitutional Affairs, outlining the Forum’s concerns
regarding the limited contribution coroners are able to make to preventing custody
deaths. We believe that the current infrastructure of the coronial system and the
discrepancies between the resources available to coroners contribute to the inconsistent
approaches to learning from deaths. Our letter appears as Annex 2 at the end of this
report.
Harriet Harman met with the Forum’s Chair and Secretary and emphasised her
commitment to strengthening the powers available to coroners to help prevent future
deaths. The Forum was invited to provide a draft clause showing how we would wish to
see the Coroners Rules strengthened, an opportunity which we welcomed.
On 30 January 2007 Harriet Harman announced that the draft Coroner Reform Bill will
now include the following measures to help coroners prevent future deaths:
• Coroners will be able to require organisations to respond to their reports and to say
what action they will take to prevent future deaths;
• The Coroner will be able to request a written response to his or her report within
a specified timeframe and there will be a legal obligation for agencies and
organisations to respond;

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• The Chief Coroner, to be appointed under the bill, will monitor the reports made and
responses received; and
• An annual report of these responses will be made to the Lord Chancellor and laid
before the House of Commons.
We welcome these measures to strengthen the powers available to coroners and
consider that the Coroner Reform Bill should be introduced at the earliest possible
opportunity.
It is the Forum’s aim that strengthening the provision for coroners to better contribute
to learning from deaths will in turn encourage more robust approaches within the
organisations who care for people in custody. If organisations are compelled to respond
to coroner’s recommendations we may be more likely to see evidence that
investigations into deaths have in fact led to a changes in practice which are sustained
and reveiwed.

Spreading knowledge about deaths
The Forum has produced a check-list for all grades of staff which is reproduced
below. It should be noted that this list is based on anecdotal information from
Forum members and is not intended to replace any existing policy, guidance or
advice issued by individual organisations.
1 Many deaths have occurred where information about a person’s risk or
vulnerability has not been communicated effectively. Always ensure that you
clearly and accurately record any relevant information about a detainee. Make
sure you understand what information you need to have access to and if it is not
available find out why not. Think about who else might need this information
(including those outside your institution), especially those who might have to care
for the person in the future.
2 Withdrawal from drugs or alcohol often heightens mental health issues, can
disguise physical illness and can also cause impulsivity and violent mood swings
(especially when the withdrawal is rapid). Withdrawal can cause suicidal ideation
even in people who have no history of self harm. History of drug or alcohol abuse
should be clearly recorded to ensure proper risk assessment.
3 There are situations where it is not possible to avoid restraining a person. Be
aware of the risks associated with this: restraint should be used as a last resort,
use the minimum force possible, try to avoid restraining people face down or in a
position which may inhibit their breathing. The person being restrained should be
monitored throughout the period of restraint and afterwards to ensure no
ill effects.
4 Policies and training on the use of restraint need to be regularly reviewed,
particularly following a death involving restraint. In addition to being trained
about the risks of asphyxia, staff should be provided with training on
de-escalation techniques.

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5 Individuals who act violently and aggressively will be experiencing increased
levels of anxiety and potentially other physical side effects. Drug and/ or alcohol
intoxication can heighten the risks to their health. If there is any sudden change
in their demeanour, medical advice should be sought immediately.
6 Remember that people who are violent or who threaten violence can also be ill or
hurt and may need urgent treatment. Sometimes the effect of alcohol or drugs
can mask other problems including head injuries. Some people fake illnesses but
even those that do can also get ill and need treatment.
7 Those who are vulnerable, mentally ill, at risk of suicide or self harm or
withdrawing from alcohol or drugs are particularly at risk if placed into
segregation. Ensure that a multidisciplinary team follows all necessary protocols
to check that the person is safe to held in segregation.
8 If you are receiving someone into your care who has been treated by a medical
professional, ensure that you understand if there are any risks to that person and
if so how they should be monitored.
9 Be aware of the location of (and how to use) any cut-down equipment supplied
or other equipment, for example for resuscitation, where you work. Staff
responsible should also be aware of any policies and procedures for dealing with
emergency situations including how to obtain emergency medical assistance.
10 Ensure that any notes you make in a detainee’s records (including medical
records) are legible and clearly annotated with your name and the date/time.
11 Look at the staff observation books/ custody records/nursing or medical records
at the beginning of each shift to make sure that you are aware of any changes or
issues to be aware of. Ensure that you document any relevant information about
detainees during your shift.
12 Think about the impact of bad news or a change in circumstances on a detainee
– have they got access to appropriate support? Ensure that staff are aware of any
anniversaries of significant events that may impact on the detainees state.
13 Find out if there have been any custody deaths where you work. If so, were any
lessons learned from the death? Find out what they were.
14 Find out if your organisation uses a system of codes to alert other staff in an
emergency situation where someone’s life is at risk.
The Prison Service’s Safer Custody News is a good example of how a regular publication
can be used to communicate lessons arising from death in custody investigations. The
newsletter is also a useful way of promoting good practice.

The Forum’s website
The Forum’s work is clearly of public interest and we are committed to ensuring that the
minutes of our meetings are openly available, along with any papers and reports we

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produce. Full time secretariat support has enabled us to set up a website which has the
potential to be used as an interactive resource to increase knowledge about deaths in
custody and improve access to information. The website is an important resource for
the Forum; over the coming months the content will be updated and new features
added to the site. We have been disappointed that a lack of resources has placed
limitations on what we can achieve with the site, including our ability to keep it updated
with news on the work we are undertaking. This is an issue which we hope will be
acknowledged by the Government’s review of our work so far.

The Government response to the JCHR’s 2006 letter
The Joint Committee on Human Rights wrote to the Government in December 2006
requesting an update on the recommendations it accepted from the Committee’s 2004
report. The Committee also asked for comment on whether the Forum was effectively
achieving change.
In its response the Government was able to report significant progress in a number of
areas, not least the sustained reduction in self-inflicted deaths in prisons 4. The
Government’s response acknowledged that the Forum is in the early stages of its work
and development but is already providing an invaluable mechanism for sharing and
analysing information about policy and practice across organisations. The Forum’s chair
provided a note to be included in the Government’s response and this was a useful
opportunity to review the group’s progress to date.

Collaborative working
In November 2006, Home Office Minister Baroness Scotland hosted an event to mark
the progress being made in efforts to reduce deaths in custody across a number of
sectors. Speakers at the event included Baroness Stern, Professor Louis Appleby of the
Department of Health, John Wadham, deputy chair of the Independent Police
Complaints Commission and current chair of the Forum and Stephen Shaw, Prisons and
Probation Ombudsman. The speakers provided information about programmes of work
across the different sectors, and the event facilitated informal discussion between all
those who contribute to this important area of work.
The event encapsulated the importance of learning lessons and sharing information
across sectors to reduce custody deaths. Discussion between members of the Forum
and of the Ministerial Roundtable on Suicides in Prisons has helped to develop plans for
the two bodies to work collaboratively and to integrate their approaches.

Links across the UK
The Forum acknowledges that those working in custodial settings in Northern Ireland
and Scotland face many of the same challenges as organisations in England and Wales.
We are committed to developing a system (or systems) that both deals with crossinstitution learning within each jurisdiction and shares that learning between

4 The number of self inflicted deaths in prisons is higher to date this calendar year than in the same period last

year. The Prison Service
have advised that self inflicted deaths in prisons are subject to large random and cyclical swings and that year on year comparisions
should not be used in isolation for evaluating the rate of deaths. A minimum frequency of three years is recommended.

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jurisdictions. Developing links with organisations in Scotland and Northern Ireland
provides a valuable opportunity for us to learn across all parts of the UK.
The Forum’s secretary has begun to build links with relevant organisations to keep them
up to date with development. By maintaining contact with organisations who wish to
engage with the Forum, we will encourage the cross-sector information sharing we
promote.

Improving inter-agency communication
Most custodial environments are highly populated, busy and stressful. It is not hard to
understand how information gets lost, even when staff are well trained and supported.
Our meetings have highlighted key issues that need to be addressed to improve internal
and inter-agency communication. An example of this is the use of the Prisoner Escort
Record (known as a PER form). The PER form is used to record information about
detainees, and can often be the only way of transferring information about risk of selfharm or vulnerability from one agency to another. We want to see a more joined-up
approach between the Prison Service and police. The PER form needs to be developed to
reflect the needs of both agencies so that it can offer the best possible protection for
detainees.
Our work is also prompting further consultation between the police and Prison Service
on ensuring that the Police National Computer (PNC) is available for prison staff. Access
to the PNC by prison staff might be very useful in helping them make better risk
assessments. By allowing the Prison Service to enter data, the police would also be more
aware of safety issues when the person concerned is next dealt with by police officers.
It seems that the two bodies have had different expectations about how and when this
can be progressed; the Forum expects to continue its focus on the issue.

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Future
goals for
the Forum

Independent chair
The Forum’s key strength is its standing amongst practitioners. Its independence, both
from Government and from member organisations, is crucial. Our members have
agreed that the Forum’s Chair should be openly and transparently appointed and should
not be seen to have any conflict of interest with the Forum’s member organisations.

Better resources
There has been an inevitable period of ‘bedding in’ for the Forum in its early stages, but
we have already addressed some of the key issues relating to custody deaths. We have
done so despite a striking lack of resources. This has resulted in many limitations in
what we are able to achieve:
• We do not currently have the resources to commission or undertake research;
• The Forum’s remit only extends to England and Wales despite the fact that the same
death in custody issues are replicated in other UK jurisdictions;
• The Forum itself currently has no remit to collate and analyse reports issued by
coroners, and does not have sufficient resources to monitor whether and how they
are implemented;
• The Forum has no formal powers and, as an independent committee, does not have
any reporting line to Ministers.
The Forum has outlined some suggested improvements to the current arrangements
(please see Annex 3) and it is hoped that the Government’s review will take the issues
we have highlighted into account.

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Annex 1

How many people die in custody in England and Wales?
Table 1
Deaths in or following police5 custody 2004/05
GENDER

Self
Natural Substance Unknown Other* Awaited** No Cause TOTAL
Inflicted Causes Misuse
Given

Male

3

14

7

0

6

1

0

31

Female

0

1

4

0

0

0

0

5

TOTAL

3

15

11

0

6

1

0

36

Deaths in or following police custody 2005/06
Male

1

7

6

0

1

5

2

22

Female

1

0

1

0

3

1

0

6

TOTAL

2

7

7

0

4

6

2

28

* It should be noted that ‘Other’ refers to either external or internal, for example head, injuries which were
identified or aggravated while the person was in custody.
** It should be noted that ‘Awaited’ refers to a case for which the post mortem result is not yet available.
*** It should be noted that ‘No Cause Given’ includes in this category all deaths where the actual cause of death
has not been ascertained at post-mortem.

Table 2
Deaths of residents of Approved Premises
YEAR

Suicide

Overdose

Natural
Causes

Accident

Other

TOTAL

2004

2

8

8

1

1

20

2005

7

6

2

0

2

17

2006

2

4

4

0

0

10

5 This indicates the number of deaths in or following police custody. This data was provided by the Independent Police Complaints
Commission (IPCC). Under the Police Reform Act 2002 police forces must refer all deaths following police contact to the IPCC. The IPCC
records deaths under four categories: fatal road traffic incidents; fatal shooting incidents; deaths in or following police custody and
deaths during or following other types of police contact.

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How many people die in custody in England and Wales? (Continued)
Table 3
Deaths in Juvenile Custody
YEAR

Suicide

Overdose

Natural
Causes

Accident

Verdict
Awaited

TOTAL

2004-05

1

0

0

1

1

3*

2005-06

0

0

0

0

1

1**

2006-07

0

0

0

0

0

0

TOTAL

1

0

0

1

2

4

* Of the three deaths in 2004-05, two were in Secure Training Centres and one was in a Young Offender Institute.
** The death in 2005-06 was in a Young Offender Institute.

Table 4
Deaths of women in prison custody
Type of death

2004/05

2005/06

2006/07

Self-inflicted

12

3

5

Natural Causes

5

4

1

Other non-natural

1

0

0

18

7

6

TOTAL

Table 5
Deaths of men in prison custody
Type of death

2004/05

2005/06

2006/07

Self-inflicted

74

71

68

Natural Causes

98

81

86

Homicide

3

2

1

Other non-natural

6

3

1

181

157

156

TOTAL

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Table 6: Classification of Deaths of Detained Patients by Gender –
1 April 2004 – 31 March 2005
Classification of death

Male

Natural Causes

151

111

262

17

18

35

-

-

-

Homicide

1

0

1

Unknown7

2

1

3

17

10

27

188

140

328

41

17

58

Self Inflicted
Substance misuse

6

Other
OVERALL TOTAL
Total Reviews undertaken8

Female

Total

Table 7: Breakdown of Deaths categorised as ‘Other’ from Table 1 –
1 April 2004 – 31 March 2005
Death categorised as Other
Awaiting information9

Male

Female

Total

1

1

2

Accidental

2

2

4

Iatrogenic

1

0

1

Drowning

1

2

3

Unsure accident/suicide

8

1

9

Fire

0

3

3

Method Unclear/other

4

1

5

17

10

27

TOTAL

Table 8: Classification of Deaths of Detained Patients by Gender –
1 April 2005 – 31 March 2006
Classification of death

Male

Natural Causes

160

144

304

29

15

44

Substance misuse

-

-

-

Homicide

0

0

0

Unknown

0

0

0

13

12

25

202

171

373

41

28

69

Self Inflicted

Other
OVERALL TOTAL
Total Reviews undertaken

6 The Mental Health Act

Female

Total

Commission does not have a separate category for deaths by misuse of drugs or alcohol

7 Unknown = Where the cause of death has been established as unknown or unascertained through inquest
8 Reviews into the circumstances surrounding the death undertaken by the Mental Health Act

Commission

9 Awaiting information on cause of death from the coroner

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Table 9: Breakdown of Deaths categorised as ‘Other’ from Table 3 –
1 April 2005 – 31 March 2006
Deaths categorised as Other

Male

Female

Total

Awaiting information

2

3

5

Accidental

2

1

3

Iatrogenic

1

0

1

Drowning

3

3

6

Unsure accident/suicide

3

2

5

Fire

0

1

1

Method Unclear/other

2

2

4

13

12

25

TOTAL

Table 10: Classification of Deaths of Detained Patients by Gender –
1 April 2006 – 31 March 2007
Classification of death

Male

Natural Causes

154

125

279

25

16

41

Substance misuse

-

-

-

Homicide

0

0

0

Unknown

1

0

1

24

6

30

204

147

351

45

22

67

Self Inflicted

Other
OVERALL TOTAL
Total Reviews undertaken

Female

Total

Table 11: Breakdown of Deaths categorised as ‘Other’ from Table 5 –
1 April 2006 – 31 March 2007
Deaths categorised as Other

Male

Female

Total

15

1

16

Accidental

3

0

3

Method Unclear/other

0

3

3

Unsure/suicide

3

1

4

Drowning

2

0

2

Fire

1

1

2

24

6

30

Awaiting information

TOTAL OTHERS

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Forum for Preventing Deaths in Custody

Annex 2

John Wadham, Chair
Kate Eves, Secretary
90 High Holborn
London
WC1V 6BH
Tel: 020 7166 3924
4 August 2006
The Rt Hon Harriet Harman MP
Minister of State for Constitutional Affairs
Selbourne House
54 Victoria Street
London SW1E 6QW

Dear Harriet
On behalf of the IPCC I chair the newly created Forum for Preventing Deaths in Custody,
established in response to the Joint Committee on Human Rights (JCHR)’s report on
deaths in custody.
The aim of the Forum is to increase learning from deaths in custody. Our work will
initially focus upon areas that fall within the responsibility of the Home Office and
Department of Health. In practice, this will mean work around deaths of people
detained in police custody, prisons, approved premises, immigration custody or those
detained under the Mental Health Act. The Forum brings together senior
representatives of 14 organisations from Government, police, prisons, coroners,
healthcare and the independent sector to learn lessons and spread best practice. Judith
Bernstein from your Department was a welcome and helpful guest at our last meeting.
I have enclosed some background information about the Forum which may be of
interest.
At a recent meeting, the Forum focused on how organisations learn lessons and share
information to prevent deaths in custody. The members of the Forum welcomed the
Coroner Reform Bill, and its publication informed our discussions about the essential
role that Coroners can play in preventing future deaths in custody.
It is evident that one of the key potential sources of learning following a custody death

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are the reports issued by Coroners under rule 43 of the Coroners’ Rules (an extract from
the minutes of our recent meeting is enclosed). Their ability to report where they
believe action could be taken to prevent similar deaths is a crucial mechanism in
highlighting organisational failings and bringing about change. However, the Forum
has identified what it considers to be a number of failings of the current provisions
under rule 43.
The Forum’s discussions have led it to conclude that the power provided under rule 43
is not currently robust enough. The rule is subject to individual interpretation by
Coroners and we understand from the Coroners Society that some Coroners believe
there is no reason to make a report as the relevant authority may already be aware of
the case. Others do not feel able to write reports about matters of concern that were
exposed at inquest but which did not affect the outcome in the particular case. In
addition to the discrepancies over how Coroners interpret rule 43, there are real
differences in how the organisations under scrutiny respond to rule 43 reports. There
was particular concern that there is no requirement on organisations to respond to
reports or for them to be publicly available. Equally concerning is that those bodies who
receive rule 43 reports are not required to monitor or provide evidence of any changes
which are instigated as a result of the Coroner’s report.
I note that in their recent report the Constitutional Affairs Committee also commented
on Rule 43 of the Coroners Rules (Para 205, House of Commons Constitutional Affairs
Committee Reform of the coroners’ system and death certification Eighth Report of
Session 2005–06). The Committee acknowledged that the Coroners Rules provide no
power for the coroner to compel the person to take action or to report back as to what
action, if any, has been taken.
It is the Forum’s view that the Coroner’s inquest provides the single most important
opportunity to identify how custodial deaths can be reduced. If this is the case the need
to make recommendations should not be relegated to the rules but is important enough
to be in the primary legislation itself. We therefore believe that the Coroner Reform Bill
provides an opportunity to establish a better system to ensure that, as far as possible,
we learn every lesson we can from these tragedies.
The Forum is fortunate to have the Coroners’ Society for England and Wales as one of its
members and has also had the opportunity to discuss its proposals with representatives
from the Coroners’ Unit within your department. However, I would very much welcome,
as the Forum’s chair, the opportunity to discuss with you whether it is possible to bring
about some of the changes we propose.
I am copying this letter to Patricia Scotland who is the Minister with overall
responsibility for the Forum and who chairs the Ministerial Roundtable on Suicide in
Prisons.
Yours sincerely
John Wadham
Chair
Forum for Preventing Deaths in Custody

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Annex 3

Strengthening the Forum for Preventing Deaths in Custody
Discussion Paper
Introduction
In the process of debating the Corporate Manslaughter Bill in the House of Commons on
16 May, the Government made a commitment to review the Forum’s current
arrangements, agreeing to report within six months on issues such as the Forum’s
autonomy from Government, increased ability to conduct research and more capacity for
information sharing.
The Corporate Manslaughter Bill was debated in the House of Lords on 22 May. During
this debate Baroness Ashton, Parliamentary Under Secretary of State for the Ministry of
Justice, outlined that the purpose of the review is to explore how the Forum can be
strengthened.
Baroness Ashton said:
“The Forum stems from the Government’s response to recommendations from the Joint
Committee on Human Rights for a taskforce dealing with deaths in custody. It works by
comparing and contrasting approaches, identifying good practice and drawing attention
to issues which need to be addressed by operational bodies or Ministers. Its terms of
reference are: “The Forum exists to learn lessons and effect change to prevent deaths in
custody”.
I understand that its first annual report is being prepared. It has made a good start in
meeting some of the criteria that the committee set for a taskforce, but we acknowledge
that there is room for improvement.
For this critical area of work to be effective, a strong focus needs to remain on personally
involving senior representatives from organisations that inspect, investigate and oversee
custody. In the review, we will look at issues such as greater autonomy from government
and improved interaction with Ministers—including the relationship with the ministerial
round table on suicide, which my honourable friend Gerry Sutcliffe chairs, its powers,
resources and capacity. The noble Lady, Baroness Stern, is, I understand, already in early
discussion with the Forum’s chairman about a seminar to explore views. That seminar
would be an integral part of the review, and we will report on progress within six months.”
The Forum will want to contribute to the Government’s review by recommending how
it should be strengthened. This paper has been prepared to prompt discussion at the
Forum’s June meeting and members are invited to comment on the proposals herein.

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2006-2007

Current arrangements
The Forum came into existence independently of the Joint Committee on Human Rights’
2004 inquiry into deaths in custody. Nevertheless, it has clearly developed with an
awareness of what the JCHR said in its report about the need for “a cross-departmental
expert task force on deaths in custody”. The Forum is making good progress towards
meeting a number of the functions outlined by the JCHR. However, it is manifest that
the current arrangements do have some weaknesses:
• The Forum does not have the resources to commission or undertake research;
• Current resources limit the Forum’s remit to England and Wales despite the fact that
the same death in custody issues are replicated in other UK jurisdictions;
• The Forum itself currently has no remit to collate and analyse reports issued by
coroners, and does not have sufficient resources to monitor whether and how they
are implemented;
• The Forum is a largely independent committee but has no formal powers and no
clear reporting lines to Ministers.
In addition, the organisational structure of the Forum could be criticised. The Chair of
the Forum is not transparently independent from its member organisations (the Chair is
currently John Wadham, Deputy Chair of the IPCC). It has no academic members and no
human rights expertise at its disposal (a criterion recommended by the JCHR for the task
force), although some of its members, and Baroness Stern as an observer, might readily
be defined as experts in human rights.

Proposals for strengthening the Forum
Strengthening the size and function of the secretariat
• The secretariat needs to fulfil three main functions: maintaining and
strengthening links with Forum members across each of the sectors;
commissioning, managing and/or conducting research into areas identified by the
Forum members; performing all administrative and support tasks for the Chair,
Forum members and related sub-committees.
• The current funding for one full time SEO post to cover each of these roles is
insufficient. As with the Chair’s position, the Secretary should be openly and
transparently recruited.
• The Forum would greatly benefit from better information sharing about the group’s
remit and the work it is undertaking. Resources to enable the maintenance and
development of the website would contribute to this.

Independent chair
• The Forum’s Chair should be openly and transparently appointed and should not be
seen to have any conflict of interest with the Forum’s member organisations.

Reviewing the Forum’s powers
• A commitment should be given to consideration to putting the Forum on a
statutory footing at some future date.

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• One of the strengths of the Forum is its independence from Government and it is
important for this autonomy to be maintained. However, a commitment by
Ministers to hold an annual meeting with the Forum’s Chair would be a welcome
signal of Ministerial commitment to the group’s work. This could be connected to
the Forum’s commitment to produce an annual report summarising the year’s work
and recommendations.
• Currently, membership and attendance at the Forum is voluntary, as is the decision
over whether to provide information to the group or its secretary. Consideration
should be given to Ministers endorsing a statement indicating the Chair’s powers to
request organisations to attend meetings and to provide information when
requested.
• Consideration should be given to the relationship between the Forum and the
Ministerial Roundtable on Suicide and to whether other organisations (such as the
Advisory Council on the Misuse of Drugs) offer a more effective organisational
model. This might be best achieved by commissioning consultants.

Reviewing the Forum’s remit
• Organisations in Scotland and Northern Ireland face many of the same issues as those in
England and Wales. Consideration should be given to resourcing the secretariat in a way
which would enable other jurisdictions to benefit from and contribute to the Forum’s
learning, either through setting up their own Forums or through sharing the existing
Forum’s secretariat. While the current Forum is supported through the Ministry of
Justice and therefore has a remit limited to England and Wales, there are clear benefits
to establishing mechanisms for cross jurisdictional learning and the current review of
the Forum provides a logical opportunity to do this.

Alternative structures for the Forum
1 Advisory Committee on Deaths in Custody
Such a Committee could emulate the structure of a group such as the statutory Advisory
Council on the Misuse of Drugs. The ACMD makes recommendations to Government on
the control of dangerous or otherwise harmful drugs, including classification and
scheduling under the Misuse of Drugs Act 1971 and its Regulations. It considers any
substance which is being or appears to be misused and which is having or appears to be
capable of having harmful effects sufficient to cause a social problem. The ACMD also
carries out in-depth inquiries into aspects of drug use that are causing particular
concern in the UK with the aim of producing considered reports that will be helpful to
policy makers and practitioners.
Another useful example is the Police Advisory Board for England and Wales. The Board has
a specific remit under section 63 of the Police Act 1996, namely to advise the Secretary of
State on general questions affecting the police in England and Wales and to consider draft
regulations under specific sections of the Police Act 1996, the Police Act 1997 and the
Police Reform Act 2002. The Secretary of State aims to attend the Board once a year and
may refer matters of serious national importance to the Board for their consideration. The

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2006-2007

Board consists of a Chair and Deputy Chair (who are appointed by the Secretary of State)
and a minimum number of members from relevant agencies, such as ACPO, the
Association of Police Authorities and the Police Federation. The Board meets four times a
year, may establish working parties to address specific issues and submits an annual
report to the Secretary of State.
The establishment of an Advisory Committee on Deaths in Custody (whether on a
statutory or non-statutory basis) could improve the profile of cross-sector work to
prevent deaths in custody. It would certainly focus Ministerial and Parliamentary
attention. Such a Committee would need to be supported by a secretariat with the
capability of commissioning (and/ or conducting) research and producing an annual
(and other) reports on preventing deaths.
One of the strengths of the Forum is its independence from Government. However, if an
Advisory Committee were established in statute, its independence would be even
clearer (under this model, it seems unlikely that the service providers would be directly
represented).
The Forum could be the basis of an Advisory Committee, or it could adapt into a more
practice-type body (see below). Under the current arrangements, the Forum’s
secretariat is funded by the Government, and although the role is funded by NOMS it is
an independent position, reporting to the Forum chair. One of the strengths of the
Forum is its independence from Government and it would be important for this
autonomy to be maintained.
2 Practitioner-led working group on Deaths in Custody
The Forum has facilitated a great deal of learning and information sharing through its
current membership of both custody providers and oversight bodies. Any future
arrangements should not undermine this practitioner input.
A practitioner-led working group with strong links to an Advisory Committee would
provide a balance between a high-level expert panel and a parallell group with a more
practical, operational approach. Such a group could be comprised of a similar
membership to the Forum: operational custody providers (DH; Prison Service, APCO) and
oversight bodies (PPO, IPCC, Coroners Society, Inspectorates etc).
The relationship between the Advisory Committee and Working Group could work in a
number of ways, such as a shared secretariat or an arrangement for a member of each
group to observe the other.
Kate Eves
Secretary to Forum for Preventing Deaths in Custody
12 June 2007

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Forum for Preventing Deaths in Custody
C/O Independent Police Complaints Commission
90 High Holborn
London
WC1V 6BH
www.ipcc.gsi.gov.uk
Tel: 08453 002 002
Email: enquiries@ipcc.gsi.gov.uk
September 2007
Reference FPDC/1
Published by the Independent Police Complaints Commission (IPCC)
© Independent Police Complaints Commission (IPCC) 2007
ISBN 0-9552083-7-8
ISBN 978-0-9552083-7-9

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