Appendix C: In-custody Death Checklist

• Author: Ken Wallentine
• Pages: 283-288

APPENDICES 283

APPENDIX C:

IN-CUSTODY DEATH CHECKLIST

An in-custody death, no matter what the cause and who

may bear responsibility, is at the top of every corrections

manager’s list of horrors. An “in-custody” death is any death

occurring while a prisoner is incarcerated, being transported

in a custodial circumstance, or being taken into custody. In-

custody deaths generally mandate at least two, and some-

times three, separate investigations, each conducted

independently, and each with its own objectives. First and

foremost, the law enforcement agency with appropriate ju-

risdiction must thoroughly investigate each in-custody death

to determine criminal responsibility. Deaths that appear to

be incontrovertibly natural might later be ruled homicides

following the autopsy, which is virtually mandatory in some

jurisdictions for an in-custody death. The second mandatory

investigation is to prepare for the inevitable civil suit. This

investigation should involve corrections managers, legal

counsel and risk management staff. A third investigation

may be conducted by facility administration to consider

breaches of policies and procedures.

The criminal investigation will likely be fully available

as part of the public record. An investigation conducted with

an eye toward civil liability principles and under the aus-

pices of legal counsel or risk management will be non-dis-

coverable as litigation preparation material. Investigators

should work closely with legal counsel to protect the confi-

dentiality of the investigation.

Investigative Approach

Sudden and unexpected in-custody deaths fall into several

general categories: prisoner-on-prisoner force, use of re-

straints, use of force by officers, suicides and accidents. In

each case initial investigative steps may mean the differ-

ence between a highly defensible civil case and an expen-

sive settlement or judgment. Following is a checklist of

essential investigative actions applicable for the majority

of in-custody deaths, derived from the good and bad experi-

ences of a risk manager and homicide prosecutor.