Appendix C: In-custody Death Checklist

AuthorKen Wallentine
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.

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