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Executive summary

Overview of 20 years of monitoring by the National Deaths in Custody Program

This monitoring report represents a significant milestone for the National Deaths in Custody Program (NDICP), in that 2011 marks 20 years since the final report was handed down by the Royal Commission into Aboriginal Deaths in Custody (RCIADIC) and therefore also represents 20 years of monitoring deaths in custody by the Australian Institute of Criminology (AIC). In this report, information is presented on deaths that occurred in custody in Australian states and territories between 1 January 1980 and 30 June 2011. Analysis is presented on the nature and circumstances of deaths in crime-related custodial settings—prison, juvenile justice and police custody and police custody-related operations (the latter includes sieges, raids, shootings and motor vehicle pursuits). Trend analysis is also presented from 1979–80 onwards for prison custody and from 1989–90 for police custody and custody-related operations.

Comparisons between these custody settings are limited. While rates of death can be presented for prison custody deaths, at the time of writing it is not possible to calculate rates of death in police custody. This is because there is a lack of reliable data on the total numbers of persons placed into police custody and/or involved in a custody-related operation each year. The AIC is currently working with state and territory police agencies to collect these data as part of the complimentary program to the NDICP—the National Police Custody Survey.

Key findings for 2008–09 to 2010–11

Overview of total deaths in custody

Over the last three financial years, the total numbers of deaths in custody have remained stable, ranging between 79 and 85 deaths each year. Although total deaths were stable, the distribution of deaths between the three crime-related custodial settings (prison, juvenile justice and police custody) showed greater fluctuation. For example, deaths in prison custody rose, from 43 deaths in 2008–09 to 58 deaths in both 2009–10 and 2010–11. While prison deaths increased, deaths in police custody and custody-related operations declined over the same period, from 36 deaths in 2008–09, to 27 deaths in 2009–10 and 26 in 2010–11. Regarding deaths in juvenile justice custody, there was only one death in 2010–11. Deaths in juvenile justice custody have remained low and occur infrequently.

In 2008–09, there were:

  • 79 total deaths in custody (15 Indigenous persons; 19%);
  • 43 deaths in prison custody (7 Indigenous persons; 16%);
  • 36 deaths in police custody and custody-related operations (8 Indigenous persons; 22%); and
  • no deaths in juvenile detention.

In 2009–10, there were:

  • 85 total deaths in custody (20 Indigenous persons; 24%);
  • 58 deaths in prison custody (14 Indigenous persons; 24%);
  • 27 deaths in police custody and custody-related operations (6 Indigenous persons; 22%);
  • no deaths in juvenile detention.

In 2010–11, there were:

  • 83 total deaths in custody (20 Indigenous persons; 24%);
  • 58 deaths in prison custody (12 Indigenous persons; 21%);
  • 24 deaths in police custody and custody-related operations (7 Indigenous persons; 29%); and
  • one Indigenous death in juvenile detention.

Following a review of the NDICP in 2011, three key indicators of performance were developed in consultation with data providing and Australian Government agencies. These indicators are:

  • trends in the number of deaths in prisons, juvenile justice and police custody, and the proportion of total deaths in each setting involving Indigenous persons;
  • trends in the rate of death per 100 adult prisoners on an average day and the rate-ratio for Indigenous and non-Indigenous deaths in police custody and custody-related operations (the rate-ratio is the relative frequency of Indigenous and non-Indigenous deaths, and is calculated by dividing the total number of deaths by the number in each cohort); and
  • trends in the causes and circumstances of deaths in all custodial settings.

The beginning of each section of this report also includes these indicators as they relate to the type of custody being analysed. The following three Tables (ie Tables 2–4) provide an overview of the key indicators in each custodial setting over the last three financial years.

Table 1 Summary of deaths in custody, 2008–09 to 2010–11
2008–09 2009–10 2010–11
n % n % n %
Prison custody—Indigenous 7 16 14 24 12 21
Prison custody—non-Indigenous 36 84 44 76 46 79
Police custody—Indigenous 8 22 6 21 7 29
Police custody—non-Indigenous 28 78 21 79 17 71
Juvenile Justice custody—Indigenous 0 0 1 100
Juvenile Justice custody—non-Indigenous 0 0 0
Total Indigenous deaths in custody 15 19 20 23 20 24
Total non-Indigenous deaths in custody 64 81 65 77 63 76
Total deaths in custody 79 100 85 100 83 100

Source: AIC NDICP 2008–09 to 2010–11 [computer file]

Table 2 Key indicators of performance—all deaths, 2008–09a
Police Prison Juvenile justice Other/Cwth
1 Indigenous 8 (22%) 7 (16%) 0 0
Non-Indigenous 28 (78%) 36 (84%) 0 0
2 Rate—Indigenous 1:4.5b 0.10c
Rate—non-Indigenous 1:1.3b 0.18c
3a Main cause—Indigenous Head injury—(38%; n=3) Natural—(71%; n=5)
Main cause—non-Indigenous External/multiple trauma—(54%; n=15) Natural—(58%; n=21)
3b Main circumstances—Indigenous Accidental—(50%; n=4) Natural—(71%; n=5)
Main circumstances—non-Indigenous Accidental—(54%; n=15) Natural—(58%; n=21)

a: Note due to the small numbers of deaths in some categories, small changes in the number of deaths may result in substantial changes in percentages

b: Rate-ratio

c: Rate per 100 prisoners on an average day (SCRCSP 2010)

Source: AIC NDICP 1979–80 to 2010–11 [computer file]

Table 3 Key indicators of performance—all deaths, 2009–10a
Police Prison Juvenile justice Other/Cwth
1 Indigenous 6 (22%) 14 (24%) 0 0
Non-Indigenous 22 (78%) 44 (76%) 0 0
2 Rate—Indigenous 1:4.5b 0.19c
Rate—non-Indigenous 1:1.3b 0.21c
3a Main cause—Indigenous External/multiple trauma—(33%; n=2) Natural—(79%; n=11)
Main cause—non-Indigenous Gunshot —(33%; n=7) Natural—(61%; n=27)
3b Main circumstances—Indigenous Accidental—(67%; n=4) Natural—(79%; n=11)
Main circumstance—non-Indigenous Accidental—(43%; n=9) Natural—(61%; n=27)

a: Note due to the small numbers of deaths in some categories, small changes in the number of deaths may result in substantial changes in percentages

b: Rate-ratio

c: Rate per 100 prisoners on an average day (SCRCSP 2011)

Source: AIC NDICP 1979–80 to 2010–11 [computer file]

Table 4 Key indicators of performance—all deaths, 2010–11a
Police Prison Juvenile justice Other/Cwth
1 Indigenous 7 (29%) 12 (21%) 1 (100%) 0
Non-Indigenous 17 (71%) 46 (79%) 0 0
2 Rate—Indigenous 1:3.4b 0.16c 0.24d
Rate—non-Indigenous 1:1.4b 0.22c
3a Main cause—Indigenous External/multiple trauma—(57%; n=4) Natural—(67%; n=8) Head injury—(100%; n=1)
Main cause—non-Indigenous Gunshot—(47%; n=8) Natural—(65%; n=30)
3b Main circumstances—Indigenous Accidental—(57%; n=4) Natural—(67%; n=8) Accidental—(100%; n=1)
Main circumstances—non-Indigenous Self-inflicted, justifiable homicide—(both 28%; n=5) Natural—(65%; n=30)

a: Note due to the small numbers of deaths in some categories, small changes in the number of deaths may result in substantial changes in percentages

b: Rate–ratio

c: Rate per 100 prisoners on an average day (SCRCSP 2012)

d: Rate per 100 Indigenous juveniles in detention on an average night (AIHW 2011a)

Source: AIC NDICP 1979–80 to 2010–11 [computer file]

Long-term trends

All deaths in custody

Throughout the 1980s, the number of deaths each year in all forms of custody increased steadily from a low of 21 deaths in 1979–80 to a high of 83 deaths in 1989–90. During the 1990s, the number of deaths in custody continued to increase, reaching a peak in 1997–98 with 109 deaths. Since this peak, there has been a moderate decline in total deaths, reaching a 20 year low in 2005–06 of 54 deaths. However, since this low, the number of deaths has again started to increase. Nevertheless, the total number of deaths in the last few years is lower than the total number of deaths seen in the late 1990s and early 2000s.

Prison deaths

Deaths in prison custody have always been higher in number than deaths in police custody (with the exception of 1985–86 and 2003–04) and as such, they make up a substantial proportion of all deaths. For this reason, trends in prison custody deaths strongly impact on overall trends for deaths in custody.

Over the 19 year period from 1 January 1980 to 30 June 1998, the number of deaths in prison custody fluctuated between a low of 15 deaths in 1979–80 and a high of 81 deaths in 1997–98 but overall, there was an increase in the numbers of deaths occurring each year. After the peak in 1997–98, the number of deaths began to decrease substantially over the following eight years to a 20 year low of 28 deaths in 2005–06. Since this low, the annual number of deaths in prison custody has started to increase again, with the totals recorded in 2009–10 and 2010–11 being at the upper end of the range.

In terms of rates of death, during the 1980s and 1990s, there was considerable fluctuation, with the annual figure ranging between 0.16 and 0.44 deaths per 100 prisoners. Since the late 1990s, the rate of death has declined considerably and has remained stable over the last six years. The rate of death in 2010–11 (0.20 per 100 prisoners), was almost half what it was in the late 1990s.

Police custody and custody-related operations deaths

During the 1980s only deaths in police institutional settings such as cells, watchhouses and police vans, were collected by the NDICP. From 1 January 1990, deaths occurring in custody-related operations, such as sieges, raids and motor vehicle pursuits were included in the monitoring of deaths in police custody. For this reason, trends in deaths in police custody and custody-related operations are best interpreted from 1989–90 onwards. Over the decade from 1989–90 to 1999–2000, the number of deaths in police custody and custody-related operations ranged between 21 and 38 deaths each year, but the overall trend can best be described as stable. In the ensuing decade from 2000–01 to 2010–11, the number of deaths each year has shown greater fluctuation. However, the numbers of deaths recorded in the last two years are at the lower end of historical levels, with 27 deaths in 2009–10 and 24 deaths in 2010–11.

Indigenous deaths in custody

Indigenous deaths in prison custody peaked in the mid to late 1990s and declined consistently each year until a 20 year low of just three deaths in 2005–06. Over the last five years, the number of Indigenous deaths has increased again, with the number recorded in 2009–10 being equal to the highest annual total ever recorded (n=14). However, it should be noted that over the last decade, the proportion of the prison population who are Indigenous has increased by six percent (SCRCSP 2012). Taking this increase in the Indigenous prison population into account, the rate of death among Indigenous prisoners has remained at an all-time low.

The recent rise in the number of Indigenous prison custody deaths is driven by an increasing number of deaths resulting from natural causes, primarily heart attacks, terminal cancer, cirrhosis of the liver and multiple serious medical conditions. The number of natural cause deaths among Indigenous prisoners recorded in 2009–10 (n=11) was the highest annual total recorded since the NDICP began and the number in 2010–11 (n=8) was the equal second highest.

Deaths in police custody and custody-related operations exhibit a different trend to that seen in prison custody deaths. Following a spike in Indigenous deaths between 2002–03 and 2004–05, annual totals have returned to levels seen in the late 1990s and early 2000s. Since 1989–90, analysis of the data showed that Indigenous persons were more likely to die in a custody-related operation, such as a motor vehicle pursuit or siege, rather than die in an institutional setting such as a police cell or watchhouse. Of the 21 Indigenous deaths in police custody over the last three years, 15 occurred in a custody-related operation; with 9 being deaths in motor vehicle pursuits, one in an ‘other/foot pursuit’, two self-inflicted shootings and one by police shooting. Of the remaining two deaths, one occurred in a police raid and the other in a siege. Whereas throughout the 1990s Indigenous deaths in police custody were more likely to occur in a close contact or institutional setting (situations where the deceased was confined in a particular location like a police cell, or they could be spoken to by police and/or their actions influenced by police conduct, such as escorting or a shooting incident), they are now more prevalent in a custody-related operation where officers do not have close contact, such as a motor vehicle or foot pursuit or a siege.

In 2010–11, one Indigenous death occurred in a juvenile detention centre. Over the last 32 years, there have been 18 deaths in juvenile justice custody, 10 involving non-Indigenous juveniles and eight involving an Indigenous juvenile. Deaths in juvenile justice custody are rare, with only one death recorded in the last five years.

Age and sex

The proportion of deaths of older sentenced prisoners has been increasing considerably in the last few years, with the number of deaths among sentenced prisoners 55 years and older being the highest ever recorded in 2009–10 (n=20) and the equal second highest in 2010–11 (n=17). This trend is at least partly due to an ageing prisoner population. At the same time, deaths of persons less than 25 years have decreased to some of the lowest annual totals in the history of the NDICP. This decline in deaths among younger prisoners is associated with fewer deaths from self-inflicted injuries. Of the persons dying from self-inflicted injuries between 1979–80 and 1999–2000, 39 percent (n=165) were young prisoners under the age of 25 years. However, since 2000–01, the proportion of such deaths among younger prisoners has declined to just 19 percent (n=33).

Unlike deaths in prison custody, which have been increasing among the older cohort, deaths in police custody and custody-related operations are more likely to involve persons under 39 years of age. Of the 901 police custody deaths where the age of the deceased is known, 71 percent (n=642) involved persons aged 39 years or younger.

With regards to the sex of persons dying in custody, the overwhelming majority of all deaths in custody are of males, which largely reflects the fact that the majority of prisoners in Australia are male. Long-term trends show that for prison custody, 96 percent (n=1,332) of all deaths are of males; for police custody the proportion is 93 percent (n=841) and for juvenile justice custody males comprise 94 percent (n=17) of all deaths.

Circumstances of deaths: Cause and manner of death, most serious offence, legal status and location

Natural cause deaths

One of the most prominent trends to emerge in recent years with regards to cause of death is the increasing number of deaths in prison custody from natural causes, which is linked to the rise in deaths of older sentenced prisoners and the ageing prisoner population. For the best part of two decades from the early 1980s to late 1990s, self-inflicted deaths, such as hanging, were generally the most common cause of deaths in prison each year. However, since 2000, the number of deaths resulting from natural causes has surpassed self-inflicted deaths as the most prevalent type of death in prison custody. The number of Indigenous natural cause deaths in 2009–10 was the highest ever recorded (n=11) and for non-Indigenous prisoners, 2009–10 was the second highest on record (n=27), with 2010–11 representing the peak in natural cause deaths among this group (n=30).

Cause and manner of deaths in police custody and custody-related operations

Cause of death relates to the medical finding regarding the death, whereas manner of death relates to the circumstances in which the person died. The primary causes of deaths in police custody and custody-related operations are external/multiple trauma, predominantly sustained in motor vehicle pursuit accidents, or from gunshots (either self-inflicted or by police) in the process of officers attempting to make an arrest. Of the 903 total deaths in police custody and custody-related operations between 1979–90 and 2010–11, the cause of death in 26 percent of cases (n=233) was from external/multiple trauma and in 23 percent (n=209) from gunshots (either self-inflicted or by police). This compares with 15 percent (n=138) that were caused by hanging and 15 percent (n=137) due to natural causes.

In relation to the manner (or circumstances) in which deaths occurred in police custody and custody-related operations, overall, 34 percent (n=308) were in accidental circumstances, such as motor vehicle pursuit accidents, followed by deaths that were self-inflicted (34%, n=304), such as those involving people shooting themselves or self-inflicting stab wounds.

Nature of offending

It was found that violent offenders are more likely to die in custody than any other type of offender, with 43 percent (n=955) of all deaths in custody falling into this group. This is not surprising when considering that almost half (46%; ABS 2011b) of all prisoners in Australia are in custody for violent offences. The second most common type of offender to die in custody were those who had committed theft-related offences (25%; n=563), followed by persons who had committed good order offences (such as breaching a domestic violence order or public drunkenness), which comprise 13 percent (n=276) of all deaths.

Legal status

Between 1979–80 and 2010–11, 68 percent (n=942) of all deaths were of sentenced prisoners. Over the 20 years from the early 1980s to early 2000s, the rate of death was generally higher among unsentenced prisoners, however since 2005–06, the rates of death have come close to parity.

This suggests that for 20 years, unsentenced prisoners have been at an increased risk of death, most likely associated with the fact that reception into prison can be a time of great stress and uncertainty for a prisoner. The considerable decline in the rate of death among unsentenced prisoners over the last 20 years has been driven by an increase in the number of unsentenced prisoners in custody, coupled with a reduction in the number of self-inflicted deaths. Over the last 20 years, the proportion of unsentenced prisoners in custody has risen by approximately 12 percent, while the proportion of self-inflicted deaths among this cohort has declined by eight percent.

Location of deaths in custody

With regards to the location where deaths in custody are most likely to occur, deaths in cells are the most prevalent in prison custody (55%; n=725), followed by deaths in a hospital after being transferred from prison (30%; n=394).

Due to the nature of operational policing, it would be expected that more deaths would occur in a public place (39%; n=297) or in a hospital following an incident in a public place (28%; n=209) than all other locations. Of the 87 deaths in all forms of police custody in the last three years of analysis (2008–09 to 2010–11), 39 deaths (45%) occurred in a public place and 20 deaths (23%) occurred in a public hospital, generally following an incident in a public place.

Deaths in police pursuits of motor vehicles

Since the collection of these data commenced (1 January 1990), there have been 206 deaths in motor vehicle pursuits, with more than three-quarters (79%, n=162) involving non-Indigenous persons. When examining deaths in motor vehicle pursuits, it was found that 60 percent (n=124) of all deaths were of persons less than 25 years old and 34 percent (n=70) were persons aged 25–39 years. Following a peak in pursuit deaths in 2001–02 (n=19), there was a steady decline over the ensuing six years. However, there was another spike in 2008–09 with 15 deaths, representing the second highest annual total ever recorded. The number of pursuit deaths in the last two years has been in line with historical trends at nine deaths per year.

Shooting deaths

It is important to make the distinction between those shooting deaths that are self-inflicted and those where a person is shot by a police officer or other government official. Since 1989–90, there have been a total of 199 deaths resulting from a shooting in police custody or custody-related operation. Of these, 105 deaths (53%) resulted from persons being shot by police, 46 percent (n=92) were persons shooting themselves while police officers were attempting to place them under arrest and one shooting death (0.5%) was by a government official. In the remaining case, the coroner was unable to determine who fired the shot that killed the deceased. Since the two peaks in deaths resulting from police shootings in 1993–94 and 1999–2000 (n=9 and n=11 respectively), the annual number of such deaths has been in decline. Over the last three years, 14 out of the 91 total deaths (15%) in all forms of police custody were persons shot by police, with a further 13 deaths (14%) being self-inflicted gunshot deaths.