In particular, State authorities are obliged to carry out
an independent, impartial, prompt and effective
investigation into the circumstances and causes of
any serious incident; to provide reparation and redress
to victims and/or their families, including adequate
financial compensation and provision of medical care
and rehabilitation; and to hold to account individual
perpetrators of unlawful killings or serious bodily harm,
ill-treatment or disappearances.
The revised UN Standard Minimum Rules for the
Treatment of Prisoners (the Nelson Mandela Rules)4
introduce in Rule 71 an explicit obligation of prison
directors to report the following incidents to a judicial
or other competent authority that is independent of the
prison administration and mandated to conduct prompt,
impartial and effective investigations into such cases:
•	 any custodial death, disappearance or serious injury
•	 any complaint or indication of torture or other cruel,
inhuman or degrading treatment or punishment
The UN Rules for the Treatment of Women Prisoners
and Non-custodial Measures for Women Offenders (the
Bangkok Rules) include additional guidance on providing
support for women who, in the course of a medical
screening, are found to have been a victim of violence,
including sexual abuse – whether before or during
custody5 – as well as women who complain of any form
of abuse.6
State authorities do not only have the responsibility to
react adequately after a death, serious injury or similar
has happened, but are also under a positive obligation
to prevent by various measures the occurrence of
avoidable death or injury, torture or ill-treatment, and
disappearances in custody.7 These responsibilities
extend to private companies in cases where custodial
duties are outsourced by the State.
While torture and enforced disappearances are legally
defined in international human rights Conventions,8
other forms of cruel, inhuman or degrading treatment
or punishment, serious injuries or custodial deaths lack
standardised definitions.

This factsheet is intended to give guidance to monitoring
bodies in assessing whether the prison authorities have
fulfilled all the obligations that arise in cases of serious
incidents, i.e. primarily recording and reporting these
cases in a timely manner, preserving evidence, and
cooperating with the investigation. In addition, the basic
elements of an effective investigation are summarised.

2. What are the main standards?
The obligation to carry out effective investigations into the
death or serious injuries of persons in State custody, as
well as into any allegations or other indications of torture
or ill-treatment, is an integral part of the right to life and
the prohibition of torture and other cruel, inhuman
or degrading treatment or punishment, as enshrined in
international and regional human rights treaties, including
the International Covenant on Civil and Political Rights.10
Moreover, the UN Convention against Torture and other
international instruments contain explicit regulations
on the responsibility of State parties to promptly and
impartially investigate any complaint or reasonable
grounds for believing that an individual has been
subjected to torture11 or to enforced disappearance.12
To ensure compliance with the obligation to carry out
effective investigations, certain legal and practical
prerequisites have to be in place. In particular:
•	 persons in custody, as well as their family members,
must have unrestricted access to internal and external
independent complaints mechanisms,13 as well as to
legal advice14
•	 prison staff, and in particular medical professionals
working in prisons, must be alert to signals of possible
•	 a complaint of torture or disappearance or any death
or serious injury in custody must be recorded16
•	 detected injuries must be accurately documented and
any other evidence preserved17
•	 the competent authorities must be notified promptly18
•	 safeguards against reprisals must be in place19

Certain groups in detention are more at risk
of being subjected to torture, other forms of
ill-treatment and/or inter-prisoner violence. These
include, among others, women, children, lesbian,
gay, bisexual, transgender and intersex (LGBTI)
prisoners, members of minority groups or persons
with disabilities. In self-governed prisons where
prison facilities (or part of them) are under the
control of groups of detainees and/or gangs,
there are high rates of violence among prisoners
(in particular vulnerable persons), leading to
serious injuries, ill-treatment and deaths.9

2 |		

The investigations into such serious incidents in custody
should be carried out by a body that is independent
of the authorities that are possibly implicated in the
death, injury, ill-treatment or disappearance. Further,
the investigations have to be promptly commenced and
carried out with expedience, and the authority must
possess the necessary competences and resources
to carry out an effective investigation and investigate
each case thoroughly. Finally, victims have a right to
be involved in the investigations.20

Penal Reform International and Association for the Prevention of Torture | Incident management and independent investigations

Select target paragraph3