DETENTION MONITORING TOOL FACTSHEET
footage, must be preserved.28 Depending on the national
regulations, the prison management will have to inform
relevant bodies within the prison administration of
the incident.
In line with Rule 71 of the Mandela Rules, the prison
director must also inform without delay a ‘judicial
or other competent authority that is independent of
the prison administration’. The exact authority will vary
from country to country, but typically such authorities
comprise the criminal police, the office of the prosecutor,
investigative judges, the coroner, prison ombudsmen,
and/or other independent investigative mechanisms. It
is the responsibility of the relevant authority to decide on
the next investigative steps. Whenever a person dies in
prison (or soon after transfer from prison), an autopsy
should be carried out; there may be highly exceptional
cases in which, as prescribed by law, an independent
authority may decide that an autopsy is not required.29
Prison authorities are obliged to fully cooperate with
the investigation, by, inter alia, providing all the names of
prisoners and staff members who might have witnessed
the events that led to the death of the individual or who
might hold other pertinent information.30
Clear rules should also be in place on informing the next
of kin of the death of their relative,31 as well as on the
return of the body upon completion of the investigation.32
In Panama, the Ministry of Government has
put in place a Protocol regarding deaths in custody.
This Protocol outlines processes for notifying
penitentiary and judicial authorities as well as
family members. The Protocol also defines the
procedures for initiating administrative and
criminal investigations into any death in custody.33
While an independent external investigation of any death
in custody is indispensable, an internal investigation
by prison authorities into any death in custody should
also take place. The aim of an internal investigation is
to establish whether structural or individual shortcomings
have led to an avoidable death, and to learn important
lessons which should be implemented to prevent
future deaths.34
The task of external independent investigation bodies
is two-fold. Firstly, to determine any individual
responsibility for the death of the person concerned,
including through omission or negligence. Secondly,
investigations of deaths in custody should establish
whether there is wider-reaching State responsibility.
The State has a duty of care vis-à-vis those it holds
in custody, which includes the provision of adequate
medical care and personal security.35 Deaths in prison
directly or indirectly caused by inadequate staffing levels,
lack of medical care or necessary medical equipment,
absence of suicide prevention programmes, etc., may
be attributable to the State.36
4 |
Following a recommendation by the European
Committee for the Prevention of Torture and
Inhuman or Degrading Treatment or Punishment,
the Director General of the Irish Prison Service
improved the structures and methods of dealing
with all deaths in custody. In addition to an
investigation by An Garda Síochána [the police],
the Coroner’s investigation and inquest and an
independent investigation by the Inspector of
Prisons, every death in custody, including those
arising from natural causes and suicide, was made
the subject of an internal review and assessment
of the circumstances of the death, to determine
accountability and any lessons learned, both
in the prison concerned and across the prison
system generally.37
What could monitoring bodies check?
• Have all cases of death in custody been recorded
within individual prison file management
systems and also centrally?
• Is a regulation in place, compliant with
international standards, guiding the prison staff
regarding their duties and required actions
in case of a death in custody? Are the prison
administration and staff aware of and trained
on the regulation?
• Has the prison administration reported without
delay all cases of death in custody to the relevant
internal and external authorities?
• Has an independent authority undertaken an
investigation into every death in custody in line
with international standards?
• Has the prison administration secured
evidence and cooperated with the investigative
authorities?
• Have the next of kin of the deceased person been
adequately informed, without delay, in every case
where there is a death in custody?
• Is an internal procedure in place to identify
lessons learned after every death?
• Have lessons learned been translated into
reforms to address the shortcomings identified?
• Are measures in place to prevent avoidable
deaths, such as a comprehensive suicide
prevention programme?
• Is statistical data on death in custody used
to identify possible structural deficiencies
leading to a higher risk of death in custody?
Is such data disaggregated to allow for analysis
of discrimination for specific categories
of prisoners?
Penal Reform International and Association for the Prevention of Torture | Incident management and independent investigations