Death in Custody – towards an International Framework for Investigation and Prevention

What are the conditions under which deaths in custody should be investigated and how can they be prevented?

Project Summary

International human rights and humanitarian law stipulate that prisoners have the right to be treated humanely and especially receive adequate medical treatment. However, so called “natural” deaths in custody are frequent and often considered “natural” because (1) there are no external signs of violence; (2) there are other health related reasons that seem obvious; and (3) time, guidelines and material is lacking to advise health care workers or international personnel on the spot how to proceed in such cases. The different partners involved in this research examined the conditions under which deaths in custody should be investigated and prevented. It resulted in the elaboration of practice guidelines which will prepare humanitarian workers for investigations of deaths in custody worldwide.

Academic Output

Executive Summary

Research on death in custody is a challenging task which must be approached from a number of angles: the humanitarian, the human rights and the legal-medical points of views, as well as from the standpoint of on-the-ground realities, that is the actual practices adopted by states when confronted with such deaths. The current project attempted such a multi-faceted study of the problem of death in custody, with a view toward developing an international framework for investigation and prevention. The following executive summary will review the steps taken during this project, as well as the results of the research. First, the report describes the trajectory and results of the qualitative study on national practices concerning death in custody. Next, a review of the legal research that took place is presented, as well as its outcomes in terms of publications. The development of draft guidelines for practitioners will then be discussed, highlighting the positive collaboration with other project partners in this regard. Finally, the outcomes of the May 2010 conference will be discussed, demonstrating how unresolved or controversial issues were taken up, and how interdisciplinary dialogue was fostered. The summary ends with an overall synthesis of results, a description of the launching event in 2011 in Geneva where the final guidelines draft was discussed with internationally well know experts. Finally, a short discussion takes place of the challenges inherent to the project and the implications for further research.

Working Paper

Working paper : Guidelines on Investigating Death in Custody

Deaths in custody are not uncommon. They may be due to natural causes; but they may also be instances of unlawful killing, or the result of ill-treatment or inadequate conditions of detention. It is often difficult for detaining authorities, investigating authorities, practitioners, and other relevant actors to ascertain precisely what they must do in order to conform to international norms and standards on investigating deaths in custody. Clear answers to practical questions are not always easily available. For instance: What procedures should be in place in order to ensure efficient management of the death scene? How should autopsies be conducted? How should evidence be processed?

To fill this gap and provide up-to-date and comprehensive guidance, the University Centre for Legal Medicine of Geneva and Lausanne, the Geneva Academy of International Humanitarian Law and Human Rights, the University of Bern, and the International Committee of the Red Cross (ICRC) – in collaboration with the International Centre for Prison Studies – have carried out research into the legal, medical and forensic aspects of investi- gating deaths in custody and prepared this set of guidelines.

Other Output

ICRC Guidelines for Investigating Death in Custody

The Guidelines for Investigating Deaths in Custody do not attempt to provide an exhaustive description of the full range of investigative bodies and techniques in existence. These vary widely from State to State, as do the relationships between such bodies. By way of reminder, the Guidelines list a number of relevant international rules; they also propose standards and good practices that should help to ensure efficient investigation of deaths in custody, regardless of the form that that may take. In some situations, non-State actors detain persons; however, the Guidelines deal exclusively with States’ obligation to investigate deaths in custody.


Death in custody: towards an international framework for investigation and prevention

To assist field staff, a first goal of this research project is to identify – and compare – the legal and regulatory texts that define, at the local, national or international level, the framework for investigation procedures and provisions to be made in the event of a death in custody. The second objective is to know how humanitarian organisations’ staff are proceeding in this situation at the moment. In this respect, it is interesting to compare the procedures implemented by CPT experts, ICRC staff, as well as members of different NGOs when dealing with a case of death in custody depending on the country and situation. Subsequently, experts in forensic medicine, as well as experts in criminology, law and prison administration, must work together to propose minimum standards to be observed in this field, including in developing countries and in humanitarian crises.


Understanding Death in Custody: A Case for a Comprehensive Definition

Prisoners sometimes die in prison, either due to natural illness, violence, suicide, or a result of imprisonment. The purpose of this study is to understand deaths in custody using qualitative methodology and to argue for a comprehensive definition of death in custody that acknowledges deaths related to the prison environment. Interviews were conducted with 33 experts, who primarily work as lawyers or forensic doctors with national and/or international organisations. Responses were coded and analysed qualitatively. Defining deaths in custody according to the place of death was deemed problematic. Experts favoured a dynamic approach emphasising the link between the detention environment and occurrence of death rather than the actual place of death. Causes of deaths and different patterns of deaths were discussed, indicating that many of these deaths are preventable. Lack of an internationally recognised standard definition of death in custody is a major concern. Key aspects such as place, time, and causes of death as well as relation to the prison environment should be debated and incorporated into the definition. Systematic identification of violence within prison institutions is critical and efforts are needed to prevent unnecessary deaths in prison and to protect vulnerable prisoners.

Article behind paywall

Research Team

Bernice Elger
University of Geneva

Vincent Chetail
Principal Member
Graduate Institute Geneva

Andrew Coyle
Principal Member
University of London

Paola Gaeta
Principal Member
University of Geneva


Patrice Mangin
Principal Member

Adam Stapleton
Principal Member
Northwestern University

Michael Thali
Principal Member
University of Berne


Morris Tidball Binz
Principal Member
International Committee of the Red Cross

Isabel Hight
Associated Member
International Committee of the Red Cross

Isabel Menegon
Associated Member





Policy domains


Host Institution