Independent Advisory Panel on Deaths in Custody

Thematic reports and individual case investigations examining deaths and serious harm in state custody. Source: iapondeathsincustody.org.

7
Thematic Reports
134
Recommendations
3
With Response
20
Case Investigations
Article 2 Investigations: Deaths and Near-Deaths in Custody
20 individual case investigations into deaths, near-deaths, serious self-harm and assaults in prison custody, commissioned under Article 2 ECHR
Reports by Year
By Custody Sector
Thematic Reports
Prison Overcrowding and Deaths in England and Wales: Findings from a Predictive Analysis and Modelling Study
Prisons & Probation
5 Sep 2025 · 3 recs · No formal response
Predictive analysis examining the association between prison overcrowding and deaths in custody (2014-2024). Projects that self-inflicted deaths could increase by 21% by 2029. Contains 3 strategic recommendations.
Report PDF
Government response summary
No formal government response published. Report published September 2025.
3 recommendations
1. Expand healthcare provision, particularly mental health services, in high-risk environments such as Category B male prisons.
2. Target suicide and self-harm prevention in prisons with occupancy rates at or above 100%.
3. Enable establishment-level research by allowing routine data sharing with independent research teams to better understand mortality risks and how to mitigate them.
Ligature Deaths in Prisons in England and Wales: Trends and Reduction Strategies
Prisons & Probation
1 Aug 2025 · 12 recs · No formal response
Analysis of ligature death trends in prisons (1999-2024). Finds ligature deaths account for 89% of self-inflicted deaths. Contains 12 recommendations across cell design, monitoring, risk assessment and research.
Report PDF
Government response summary
No formal government response published. Report discussed at Ministerial Board on Deaths in Custody (November 2024) prior to final publication. Report published April 2025.
12 recommendations
1. Encourage cross-establishment sharing of prison audit findings to improve consistency in cell design and suicide prevention approaches between prisons, so that priorities and action plans could be identified to establish a national ligature death prevention strategy.
2. Establish national "minimum expectations" in cell ligature safety standards.
3. Review and remove ligature points in both new-built and old cells (particularly those on windows, beds, and doors or cell gates) while maintaining an unrestrictive and humane environment, with reference to cellular accommodation design guides and checklists.
4. High-priority areas should be identified to guide ongoing work addressing ligature points such as windows in older prisons, with progress reviewed regularly.
5. Personnel involved in designing ligature-resistant cells should recognise that a low height of ligature point does not indicate safety.
6. Explore the usability of alternative materials for ligature-resistant bedding in cells.
7. Establish criteria in the level of supervision required for 'at risk' prisoners to ensure prompt response to ligature use events by staff.
8. Improve information sharing and communication between prison staff and other professionals, particularly with healthcare services.
9. Post-incident early reviews should be conducted to identify factors, including potential ligature points in prisoners' environment, which may have been inadequately addressed to prevent death.
10. Risk assessment and intervention frameworks should be evidence-based (e.g., by considering findings from high quality research identifying risk factors).
11. Improve risk assessment by incorporating findings of new evidence on role of structured approaches to support professional decision-making, particularly at the end of the ACCT process.
12. Encourage collaboration between prison establishments and researchers to evaluate impact of changes to policies and efficacy of existing and new suicide prevention strategies.
More Than a Paper Exercise: Enhancing the Impact of Prevention of Future Death Reports
Cross-cutting
1 Sep 2023 · 18 recs · No formal response
Review of how Prevention of Future Death reports are used across the custody system. Examines the role of coroners, recipients, and oversight bodies. Contains 18 recommendations for improving the impact and follow-up of PFD reports.
Report PDF
Government response summary
No formal government response published.
18 recommendations
1. All should ensure that their approach to the PFD process is open, non-defensive and that the public interest in preventing future deaths is prioritised over reputational considerations at every stage. For example, lawyers should be specifically instructed not to take …
2. All should ensure that they approach the PFD process with full candour and proactively provide all relevant information at the earliest appropriate stage.
3. The Ministry of Justice (MoJ) should adequately resource the Chief Coroner's Office to produce a yearly review of PFD reports for custody deaths. This should aim to identify themes and trends, and report on the timeliness and quality of responses, …
4. The MoJ should provide dedicated funding to the Chief Coroner's Office to enable it to centrally record the conclusions of inquest juries, even where no PFD report is issued, and publish them online for easy referral in the same way …
5. The Department of Health and Social Care (DHSC) should give serious consideration to the creation of an independent body for investigating deaths of those formally or informally detained in mental health settings. This would remove the anomaly between the investigation …
6. Recipients of PFD reports relating to deaths in custody should hold a "post-inquest learning review" meeting following the conclusion of an inquest, attended by the key persons who participated in the inquest. This will help to ensure both an efficient …
7. Recipients of PFD reports should ensure that their responses are timely, high quality, case-specific, and fully informed by the inquest evidence and findings. Where the response relays that action will be taken, actions should be identified in precise terms and …
8. All should ensure PFD reports are shared 'horizontally' with relevant equivalents across the country – for example, other police forces, prisons, and mental health trusts – particularly where there may be scope for national learning, to ensure opportunities to make …
9. Leaders of local custody bodies, such as prison governors, should consider adopting the approach of Milton Keynes Together Safeguarding Partnership and hold periodic meetings of representatives from all custodial settings to review relevant PFD reports, with participation, where appropriate, of …
10. Government should consider what enhanced role independent bodies might play in auditing, following up on, and reporting on PFD reports, and this could include establishing a new body for this purpose. More effective oversight of the sharing, use, and implementation …
11. The Chief Coroner should consider supplementing his guidance on PFD reports to further address when it may be appropriate, in compliance with the statutory requirements, to make interim PFD reports and the importance of doing so, in particular where a …
12. The Chief Coroner should consider supplementing his guidance to advise coroners on the importance of ensuring relevant evidence is provided at a sufficiently early stage, in particular where coroners consider there may be a need for urgent action. The guidance …
13. The Chief Coroner's Office should review and consider expanding the list of organisations which should receive PFD reports on deaths in state custody (found at paragraphs 56 and 57 of the guidance on PFD reports) to ensure more comprehensive coverage …
14. The Chief Coroner's Office should ensure that its online database of PFD reports is fully searchable by thematic areas and location, and that deaths in detention (particularly under the Mental Health Act 1983 (MHA) are readily identifiable. Consideration should be …
15. The Ministerial Board on Deaths in Custody secretariat should send PFD reports on deaths in custody to the House of Commons Justice, Health, and Home Affairs Select Committees, which should consider taking evidence and reporting on significant themes.
16. All organisations which scrutinise places of detention should make explicit use of PFD reports to inform their investigations, inspections, and thematic reports and bulletins, including monitoring and reporting on progress made against responses to PFD reports by services and agencies. …
17. The Ministerial Board on Deaths in Custody (MBDC) secretariat should continue to review and distribute PFD reports relating to death in custody to MBDC members for the purpose of sharing learning, and consider involving all relevant agencies and partners who …
18. The Judicial College should work with the Chief Coroner to deliver mandatory training to coroners on the purpose, process, publication, and distribution of PFD reports, as well as the role of independent scrutiny bodies, incorporating the perspective of bereaved families.
Preventing Deaths at Point of Arrest, During and After Police Custody
Police Custody
1 Dec 2022 · 25 recs · Response Sep 2024
Thematic report examining deaths at point of arrest, during police custody and apparent post-custody suicides. Based on evidence gathering exercise with police forces, PCCs, healthcare providers and bereaved families. Contains 25 recommendations.
Report PDF Response document
Government response summary
No direct formal response to the 25 recommendations. Policing Minister Rt Hon Dame Diana Johnson DBE MP wrote a general response (20 September 2024) on related topics including post-custody suicides, Right Care Right Person, and diversion from custody. The Minister stated commitment to preventing deaths in custody and ensuring transparency and accountability, but did not address specific recommendations. Association of Police and Crime Commissioners published updated guidance for policing leaders on preventing deaths (April 2025) drawing on the IAPDC report.
25 recommendations
1. Individual forces and healthcare partners should develop and implement an agreement about mental health response in their area. Building on progress made by the cross-agency Mental Health Crisis Care Concordat, understanding must be developed and shared of what support is …
2. Steps should be taken to ensure a greater scale and coverage of mental health support. Although general healthcare, including within police custody, is usually provided on a 24-hour basis, mental health support through liaison and diversion services is patchier during …
3. Police and Crime Commissioners should scrutinise the use of adequate risk assessment procedures and protocols on safeguarding for suicide prevention, drug and alcohol misuse. This includes markers on the Police National Computer, medication checks, and monitoring of protection of vulnerable …
4. While we recognise the range of existing training available for forces, individual forces and liaison and diversion staff, supported by the College of Policing, NHS England, Royal College of Nursing, and the National Police Chiefs Council mental health and neurodiversity …
5. The Department of Health and Social Care and the Home Office must end the use of police custody as a place of safety, as recommended by Sir Simon Wessely in his review and the intent set out in the Reforming …
6. NHS Integrated Care Boards and Foundation Trusts must take steps to ensure adequate inpatient facilities are available for urgent admission under the Mental Health Act. The onus for this should not be placed on frontline police officers.
7. Individual forces should liaise with liaison and diversion services, local health providers and community and voluntary sector organisations to explore options for support available on release for any person identified as at risk of self-inflicted death. This could be strengthened …
8. NHS England and NHS Wales should consider a further large-scale independent evaluation of liaison and diversion services across England and Wales to assess their current effectiveness and to identify what areas of the programme could be improved to better support …
9. Individual forces should consider how data on apparent post-custody suicides can be improved. This could include assessing whether reported data accurately reflects deaths which occur later than 48 hours after release. There should be a review of what support and …
10. Relevant policing, health and local authority partners should work together to standardise aspects of pre-release risk assessments conducted to identify vulnerabilities and in particular indicators of increased suicide risk, with follow-ups put in place where a risk is identified.
11. Individual forces should evaluate and apply interventions to support the reduction of post-custody suicides, with learning and good practice shared with police in other geographical areas.
12. Individual forces, with the College of Policing, should identify and share the mechanisms they use for acting on learning after a death. This could involve a more standardised, consistent approach, and the distilling and sharing of relevant coroners' or Independent …
13. The College of Policing should ensure that training for custody officers and their Authorised Professional Practice (APP) for custody is regularly reviewed and kept up to date, having considered any learning and recommendations following custody deaths. The College of Policing …
14. Individual forces, the IOPC, the National Police Chiefs Council, the College of Policing, and any other relevant parties to an incident relating to a death should take steps to ensure emerging learning from deaths is shared as a priority following …
15. Individual forces should integrate the views and perspectives of bereaved families into their processes for learning from a death, and ensure steps taken in response are communicated clearly and respectfully to families during and after implementation.
16. Individual forces and the IOPC should explore how to define and record 'near miss' incidents and their investigation. Data on, and findings from, near misses should then be collated and shared to inform learning and training to avoid such incidents …
17. The IOPC and the Home Office should work to provide further information about deaths that are currently recorded under the general classification of 'other deaths following police contact', particularly providing key details regarding themes and learning taken from these deaths. …
18. Individual forces should take steps to ensure a proactive learning approach when responding to lessons following a death or near miss. This could involve an independent facilitator in lessons-learned exercises after a critical incident in custody. This could provide unbiased …
19. Individual forces should make use of national seminars to share and discuss best practice. These could be focused on specific topics and be organised in conjunction with other stakeholders. As described by the Durham PCC, these conferences can be held …
20. Individual forces, the National Police Chiefs Council (NPCC), the College of Policing and PCCs should take steps to improve how they share with colleagues elsewhere the practice in the three thematic areas covered by this report. This exercise highlighted several …
21. Individual forces, the Home Office, the NPCC, the IOPC and the College of Policing should take active steps to build and disseminate a greater understanding of the role of disproportionality and race in relation to deaths in police custody, particularly …
22. PCCs should lead local scrutiny panels and expand their focus to include the examination of data relating to custody performance. These panels could focus on data relating to disproportionality, as well as mental health and substance misuse prevalence.
23. Individual forces must prioritise safety within the broader culture of custody suites. This includes placing emphasis on keeping people safe in custody and looking after them properly with compassion and dignity, as set out by the Good Police Custody guide …
24. Police and Crime Commissioners should appoint a Portfolio Lead for the prevention of deaths in custody and apparent post-custody suicides. This individual should work alongside the Policing Minister, the police and the IAPDC to drive forward work to reduce the …
25. Police custody healthcare teams, liaison and diversion services, NHS England and NHS Wales should take an integrated approach to facilitating the treatment of detainees, especially given evidence of co-morbidity and the prevalence of drug and alcohol misuse together with mental …
Protecting Lives: A Cross-System Approach to Addressing Alcohol and Drug-Related Deaths within the Criminal Justice System
Cross-cutting
14 Jan 2022 · Joint with Royal College of General Practitioners · 10 recs · Response Mar 2022
Joint report with the Royal College of General Practitioners examining cross-system approaches to preventing drug and alcohol-related deaths in all forms of state custody. Contains 10 recommendations.
Report PDF Response document
Government response summary
Joint response from MBDC Ministers Kit Malthouse MP, Victoria Atkins MP, and Gillian Keegan MP (15 March 2022). The response noted the report "with interest" and stated the government's 10-Year Drugs Strategy "From harm to hope" (December 2021) aligns with a number of IAPDC recommendations. Specific actions cited: exploring long-acting buprenorphine availability in prisons, and supplying naloxone to staff in prisons and approved premises. No per-recommendation commitments made.
10 recommendations
1. The number of substance misuse-related deaths in the criminal justice system is still unclear. The last dataset analysed for deaths in prison is now five years old. The Office for National Statistics (ONS) and HMPPS should collaborate again on a …
2. The use of naloxone as a form of harm-reduction for opioid abuse should be expanded, with training provided to prison staff (and members of the public) to raise awareness of overdose response. The use of naloxone would help prevent deaths …
3. While funding has been sourced for the rollout of some Court-based Liaison and Diversion services (L&D) and Community Sentence Treatment Requirements (CSTRs), additional resources are still required to ensure greater coverage. Both initiatives help divert individuals with substance misuse problems …
4. Drug and alcohol misuse is often associated with, or caused by, wider social and economic issues. A streamlined approach which encourages services to be collaborative, and ideally co-located, is required to enable services to work in an integrated way in …
5. NHS England and NHS Wales, HMPPS and the Ministry of Justice should set out a specific approach to substance misuse treatment for women in the criminal justice system and wider community health to account for the large catchment areas of …
6. People are at particular risk of substance misuse-related death when they are in transition between prison and the community. The introduction of 'bridging liaison' roles, created jointly by HMPPS and NHS England and NHS Wales, would reduce the risk of …
7. The increased use of the newly available formulation of prolonged-release buprenorphine as an opioid substitution therapy (OST), given as weekly or monthly injection, would help to reduce risk and improve the continuity of treatment to service users as they move …
8. To enable the learning of lessons by services and establishments following a substance-related death, independent recommendations made by investigators and scrutiny bodies should be given to specific owners and made with the clear appreciation as to what changes are realistically …
9. Investigators of substance misuse-related deaths should take into account both the clinical and security factors relevant to the incident. Where possible, scrutiny bodies should identify where there had been missed opportunities for diversion. Staff from the relevant agencies should be …
10. NHS England and Health Inspectorate Wales should work in collaboration with investigators to ensure commissioned independent clinical reviewers who assist in investigations into substance misuse-related deaths are qualified and experienced in the subject area. Experienced reviewers should also be involved …
Avoidable Natural Deaths in Prison Custody: Putting Things Right
Prisons & Probation
29 Sep 2020 · Joint with Royal College of Nursing · 15 recs · No formal response
Joint report with the Royal College of Nursing examining avoidable natural deaths in prison custody. Contains 15 recommendations for improving healthcare provision and reducing preventable deaths.
Report PDF
Government response summary
No formal government response published. Recommendations informed the IAPDC-HMPPS agreement on reducing and preventing deaths in prison (July 2023). The IAPDC states the 2020 recommendations "still stand" as of 2025, suggesting limited implementation.
15 recommendations
1. Develop extended health information sharing, involving prisoners' families where possible, improving and sharing information in person escort records (PERS) and introducing prisoner 'medical passports' to facilitate a continuation of prescribing.
2. Implement clinical coding systems across prison healthcare departments to ensure standardisation of reporting and data transfer.
3. Implement a uniform comprehensive care pathway across prison healthcare that is evidence based and applies a joint approach across all agencies, departments and services.
4. Implement the Quality Outcomes Framework (QOF) across the prison estate, including employing administrators to update records and make summaries and Code diagnoses.
5. Overhaul secondary care referrals, including through developing: secondary care clinics in prisons in major specialities; an escort algorithm to prioritise outpatient visits and escorts; a contracted out service to conduct escorts as in the court service; a halt to, and …
6. Conduct an in-depth review of the characteristics of natural deaths in women and BAME individuals and make specific amendments where appropriate.
7. Develop a joint health and justice older persons strategy for the criminal justice system. This should be integrated with local social care plans and provision.
8. Develop a dementia care pathway across the prison estate including making all prisons dementia friendly, with clear signage, well-lit areas preferably with as much natural light as possible, and consistently plain and levelled flooring.
9. Reassess the policy on Do Not Resuscitate decisions and their use within the prison healthcare system to make clear at what time and in which situations it is appropriate to administer CPR.
10. Review and overhaul the process of compassionate release from custody to make sure that it is clear, transparent, timely and fair.
11. Review the application of the Care Act in prisons and for people on release from custody with a view to establishing minimum standards, sharing good practice and identifying poor or unacceptable performance under the Act.
12. Implement the 'Dying Well in Custody' charter across prisons to maintain dignity, better support families and deliver uniform palliative care.
13. Encourage student placements and rotational training schemes across disciplines. Streamline security clearance arrangements. Develop a forensic training academy and skills lab. Establish prison medicine as a sub-speciality.
14. Convene regular standing meetings between the Prison and Probation Ombudsman, the office of the Chief Coroner, prison governors and healthcare managers to consider often repeated recommendations with solutions found and actioned. Create a national oversight mechanism to monitor deaths in …
15. Improve standards of post-death investigations so that failures are identified and changes made. Ensure that non self-inflicted deaths are fully investigated by independent specialists.
Preventing the Deaths of Women in Prison
Prisons & Probation
28 Mar 2017 · 51 recs · Response May 2021
Examination of the factors contributing to deaths of women in prison, covering the journey from community through courts to custody. Contains 51 recommendations across pre-custody, reception, in-custody care, and system-wide reform.
Report PDF Response document
Government response summary
All recommendations accepted by ministers. Implementation mapped into the Female Offender Strategy (June 2018). Prisons Minister Alex Chalk MP provided a detailed progress update (11 May 2021) covering: rollout of Offender Management in Custody (OMiC) keyworker scheme across women's estate; Women's Estate Self Harm Task Force (established April 2020) delivering trauma-informed initiatives, additional counselling, and women-specific training; revised ACCT v6 rolled out in female estate; renewed £500k Samaritans Listener scheme grant; Women's Estate Health and Social Care Review launched. However, Public Accounts Committee (2022) found only 31 of 65 Female Offender Strategy commitments fully achieved.
51 recommendations
1. Ensure adequate information is provided to the courts including reports covering mental health need, vulnerability and safeguarding concerns.
2. Encourage greater use of community sentences by the courts to include treatment orders.
3. Coordinate national and local government leadership focus on prevention and the strategic reduction of women’s prison numbers.
4. Roll-out liaison and diversion services across police stations and courts
5. Increase investment in women’s services in the community and look to models of local authority pooled budgeting as in Greater Manchester.
6. Develop a sustained network of women’s centres.
7. Co-ordinate a multi-disciplinary response to vulnerable women involving family support and domestic violence services as well as health and justice provision.
8. End delays in receiving prescribed medication on arrival and improve contact between GPs and prison healthcare.
9. Improve arrangements for first night in custody.
10. Conduct transfers in a longer-term planned manner, with more information provided to the women being moved.
11. Improve drug and alcohol treatment in custody linked to treatment in the community.
12. Encourage and support self-help groups and peer support, in particular sustaining a team of Samaritan Listeners and Insiders.
13. Improve physical environment and remove ligature points from women’s cells/rooms.
14. Ensure multi-disciplinary ACCT reviews, specifically including mental health staff.
15. Provide mandatory mental health awareness training for staff and establish a system of staff support and supervision.
16. Enable and support women to maintain family contact (see section on family contact).
17. Focus the whole prison environment on promoting the mental and physical health and wellbeing of all prisoners in a trauma-informed way (see section on mental health).
18. Develop a gender-aware and trauma-informed environment in all women’s prisons including staff training on the impact of separation and loss, and awareness of perinatal mental health and support for women at risk.
19. Roll out higher level of emergency response training for all staff.
20. Ensure every Mental Health Trust has a clinical lead for women’s mental health.
21. Provide a greater range of mental health and substance misuse treatments, including the provision of counselling services and talking therapies, in the community.
22. Provide counselling services to all women prisoners. Each women’s prison should employ a counsellor with placements for trainees routinely, and a national lead for counselling services should be instituted.
23. Establish thorough-going mental health assessments for all within first 24 hours of arrival in custody.
24. Review implementation of the Care Act 2014 which placed preventative duties on local authorities and required them to meet social care needs
25. Ensure access to secure mental health accommodation is available in a timely manner to those who need it, prisons should not be used as places of safety.
26. Ensure healthcare staff routinely share matters of risk of suicide with prison staff, in accordance with the IAP’s Information Sharing Statement.
27. Develop a shared care plan for each woman to which she can contribute.
28. Plan the transfers of women between prisons carefully with a standard form/template developed for handover and information regarding risk of suicide and self-harm.
29. Ensure that women can retain their own information on transfer including their pin phone numbers.
30. Learn and embed lessons set out by coroners, the Prison and Probation Ombudsman and the IPCC in improved transfer of information between agencies and establishments to keep women safe.
31. Achieve compatibility between health information systems in England and Wales
32. Put in place local information sharing protocols between all relevant health and justice, including liaison and diversion, services.
33. Adopt nationally the updated Person Escort Record (PER) form with space to add information about risk as endorsed by the National Police Chief’s Council.
34. Improve communication and information transfer between GP’s, midwives and prison healthcare.
35. Improve communication between agencies during preparation for release.
36. Impose community sentences, with family and domestic violence support where necessary, unless the offending is so serious or dangerous that only a custodial penalty will suffice.
37. Create a custodial system closer to homes in smaller more residential accommodation linked to health and other local agencies.
38. Implement in-cell telephones in all women’s prisons, and enable women to make free emergency telephone calls where necessary.
39. Maximise family contact through better technology, to include use of videoconferencing and visiting arrangements.
40. Consider and extend the use of release on temporary license (RoTL).
41. Train and support staff for work with families and appoint family support/liaison officers in all establishments.
42. Establish and maintain sustained partnerships with voluntary organisations offering family support.
43. Provide and make accessible to women in prison the 24 hour Freephone, National Domestic Violence Hotline, run in partnership between Woman’s Aid and Refuge.
44. Encourage family engagement in ACCT reviews.
45. Ensure preparation for release is ongoing, forming part of a regularly reviewed sentence plan and engendering hope and a sense of future important to suicide prevention.
46. Increase use of release on temporary license (ROTL) to enable women to resume contact with family and caring responsibilities and to undertake voluntary or paid work and training in the community.
47. Oblige local authorities to provide safe housing for women prisoners who would otherwise become homeless at the point of release.
48. Continue on release, if started in prison, mental healthcare and treatment for addictions.
49. Provide social care support and mentoring on release for women with learning disabilities or learning difficulties.
50. Review, and reinforce, compliance with Section 10 of the Offender Rehabilitation Act which requires commissioners and providers to take account of the particular needs of women in making supervision and rehabilitation arrangements.
51. End recall to custody for most forms of technical breach of license and strengthen supervision arrangements instead.
Data from Independent Advisory Panel on Deaths in Custody. Covers thematic reports and individual case investigations.