DETENTION MONITORING TOOL FACTSHEET
Main references
• International Covenant on Civil and Political
Rights, Articles 2 (2) and (3), 6 (1), 7, 9 and 10 (1)
• UN Convention against Torture and Other
Cruel, Inhuman or Degrading Treatment
or Punishment, Articles 1, 4, 12, 13 and 16
• International Convention for the Protection
of All Persons from Enforced Disappearance,
Articles 2, 3 and 12
• UN Principles on the Effective Prevention and
Investigation of Extra-legal, Arbitrary and
Summary Executions
• UN Manual on the Effective Investigation
and Documentation of Torture and Other
Cruel, Inhuman or Degrading Treatment
or Punishment (Istanbul Protocol)
• UN Standard Minimum Rules for the Treatment
of Prisoners (the Nelson Mandela Rules), Rules
7–8, 30–31, 34, 54, 56–57, 68–69, 71–72
• UN Rules for the Treatment of Women
Prisoners and Non-custodial Measures
for Women Offenders (the Bangkok Rules),
Rules 6–7, 25
• Inter-American Convention to Prevent and
Punish Torture, Article 8
3. Types and situations of risk
Deaths in custody
‘Death in custody’ refers (as a minimum)22 to: any
death of a person deprived of their liberty, whether in
prison, a pre-trial or immigration detention facility, police
custody, prison hospital or other place of detention, or
during transport to or between such places; a death of
a detainee in the course of an attempted escape; any
death of a person deprived of their liberty transferred to
a civil hospital before dying; or of a person previously
deprived of their liberty who was released from custody
shortly before dying.23
The reasons for a death in custody can be manifold,
and many deaths may not involve any State or
individual responsibility. Nevertheless, all deaths in
custody must be registered and reported to the
competent authorities,24 including deaths that appear
to have happened due to natural causes or suicide.25
It is important to identify deaths caused by neglect or
omission in order to prevent any concealment of illtreatment or another crime, to determine if the death
could have been avoided, to identify systemic failings,
and to prevent comparable situations from emerging in
the future.
• UN Rules for the Protection of Juveniles
Deprived of their Liberty (the Havana Rules),
paras. 20–22, 24, 50, 56–57, 75–78
• UN Revised Minnesota Protocol on the
Investigation of Potentially Unlawful Death
• Guidelines on the Conditions of Arrest, Police
Custody and Pre-Trial Detention in Africa (the
Luanda Guidelines), part V
• Principles and Best Practices on the Protection
of Persons Deprived of Liberty in the Americas,
Principle XXIII
• Guidelines and Measures for the Prohibition
and Prevention of Torture, Cruel, Inhuman or
Degrading Treatment or Punishment in Africa
(the Robben Island Guidelines),21 provisions
18–19, 49–50
• Guidelines of the Committee of Ministers of
the Council of Europe on eradicating impunity
for serious human rights violations
• European Committee for the Prevention of
Torture and Inhuman or Degrading Treatment
or Punishment, Combating Impunity, 14th
General Report, 2004; and Documenting and
Reporting Medical Evidence of Ill-Treatment,
23rd General Report, 2013
Every prison system should have a regulation in place
outlining the necessary steps if an apparent death
(where there are no signs of life) is discovered in a prison.
These steps could comprise, for instance, the obligation
to call emergency services, to stay with the casualty, or
to attempt resuscitation until a healthcare professional
arrives. Further, the securing of the cell or other place
where a casualty was found as a possible crime scene
should be regulated to ensure any evidence is preserved,
as required by Rule 71 of the Nelson Mandela Rules.
The Department of Corrective Services of Western
Australia has a comprehensive policy directive
in place on the procedures to follow in case of a
death in custody. This directive includes a checklist
intended as a guide to assist prison staff with their
duties and required actions in the event of a death
in custody.26
An incident report should be completed with the input
of all staff members involved and an entry should be
made in the prisoner file management system (which
could be a journal on serious incidents or an electronic
database).27 All documentation pertaining to the
deceased detainee, including medical files, should be
retained and other potential evidence, such as CCTV
Penal Reform International and Association for the Prevention of Torture | Incident management and independent investigations
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