Preventing deaths in police
custody
The role of the custody visitor
Deborah Coles co-director INQUEST
About INQUEST
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Advice
Casework
Policy and research
Campaigning
Police custody deaths in numbers
• 269 deaths in police custody in last 10
years (to October 2013)
• 47 black and minority ethnic deaths
• INQUEST has worked on 206 police
custody deaths in the last 10 years
Case study: Andrzej Rymarzak
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Alcohol intoxication
Failure to follow procedure including:
Failure to conduct rousing checks
Failure to provide adequate medical care
and treatment
Case study: Thomas Orchard
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Mental health
Restraint
Use of Emergency Response Belt (ERM)
Taken to police custody
Adequacy of medical care
Key issues arising from INQUEST
casework on deaths in police custody
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Mental health
Restraint (incl. Taser use)
Drug and alcohol intoxication
Drug swallowing
Medical care and role of FME
Self harm and self-inflicted deaths
Cont’d…
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Communication problems
Training
Record keeping/monitoring
Cell design/Risk Assessments/Custodial Health
& Safety
HMIP/HMIC inspections of police
custody
• Poor recording and analysis of use of force
• Authorisation and incidence of strip searches
and use of force – use of strip clothing
• Too many mental health detainees in police
custody
• Unsatisfactory risk management
Regulation 28 Prevention of Future Deaths
reports (previously Rule 43 reports) and
narrative conclusions/verdicts
Learning tool to prevent future fatalities
• More meaningful outcome for bereaved families
Current limitations:
• Lack of detailed monitoring, analysis or follow up
Learning from deaths in custody
• The need for a more co-ordinated role on postinquest learning from regulation, inspection and
monitoring bodies
• Integration of investigation and inquest findings
and follow-up
• Incorporate post inquest learning in Custody
visitor role
About INQUEST
• Learning from Death in Custody Inquests
http://www.inquest.org.uk/publications/learning-from-death-in-custodyinquests
• ‘Inquest Law’ magazine – subscribe:
http://www.inquest.org.uk/ilg/inquest-law-magazine
inquest@inquest.org.uk
www.inquest.org.uk