Incident management
and independent
Addressing risk factors to prevent torture and ill-treatment
Where the events in issue lie wholly, or in large part, within the exclusive knowledge of the authorities,
as in the case of persons within their control in detention, strong presumptions of fact will arise in respect
of injuries and death occurring during that detention. Indeed, the burden of proof [in such cases] may be
regarded as resting on the authorities to provide a satisfactory and convincing explanation.1
(European Court of Human Rights)

1. Introduction and context
Deaths or serious injuries of persons in custody,
disappearances of individuals, and allegations of torture
and other forms of ill-treatment by detainees or indications
that a detainee might have been subjected to ill-treatment
can be summarised as ‘serious incidents’ in custody,2
which can have a variety of different causes. While this
factsheet focuses on prisons, some of the guidance is
equally applicable for monitoring bodies in addressing
serious incidents in other detention settings, such as
police custody and immigration detention facilities.
A prisoner can die from so-called ‘natural causes’ such
as illness or old age. There can also be deaths or serious
injuries due to suicide or suicide attempts, prison staff
violence (including torture), sexual abuse (including rape),
inter-prisoner violence, legitimate or excessive use of
force by prison staff, self-harm, inadequate medical care,
drug overdoses, or sports or work-related accidents.
Deaths or serious injuries in custody can therefore
occur due to accidents, for which nobody bears any
responsibility, or on the other hand they can be due to
negligence or lack of care, or they can be directly caused
by another person, including prison staff.
All these serious incidents could constitute a violation
of one or more of the most fundamental human
rights, in particular the right to life and the prohibition



of torture and other forms of ill-treatment, as well as
the right not to be arbitrarily detained. There is therefore
a responsibility on the State to account for any death,
injury or disappearance of persons it detains, regardless
of how the incident occurred.
International standards consequently require that each
serious incident in custody triggers and is followed up
by a number of measures, with the aim of clarifying the
facts and establishing, where applicable, State and/
or individual responsibility for the harm suffered, and
to prevent as far as possible such incidents in the future.

The credibility of the prohibition of torture and
other forms of ill-treatment is undermined each
time officials responsible for such offences are not
held to account for their actions. If the emergence
of information indicative of ill-treatment is not
followed by a prompt and effective response, those
minded to ill-treat persons deprived of their liberty
will quickly come to believe – and with very good
reason – that they can do so with impunity.3


European Committee for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment


Select target paragraph3