Spreading Knowledge about Deaths in Custody

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 issues 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: restraints 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.

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 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 or 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.

Forum for Preventing Deaths in Custody Annual Report 2006/2007 (pdf168kb)