Non-custodial deaths: missing, ignored or unimportant?

Jake Phillips, Loraine Gelsthorpe and Nicky Padfield
Wednesday, 9 May 2018

Whereas deaths in 'secure' or custodial settings have received considerable academic and policy attention, deaths that occur amongst those in the community have received far less attention.

Whilst the Prisons and Probation Ombudsman is empowered to investigate such deaths, this has never happened. Yet the mortality rate amongst people who are serving a sentence in the community is consistently higher than in the general population, and perhaps even higher than in custody.

In recent years, we have undertaken two studies (on behalf of the Howard League and the Equality and Human Rights Commission) which have sought to investigate this important social issue. In an article published in Criminology and Criminal Justice we have provided an overview of the findings and reflected upon the implications of our work.


We have found that women are more at risk of dying whilst serving a sentence in the community when compared to the general population, and that drug-related deaths and suicide feature heavily. In the research, for the Equality and Human Rights Commission, we focused on people who died of non-natural causes within 28 days of leaving prison and died by suspected suicide within 48 hours of being released from police custody.

Our analysis of government data found that the first week after leaving prison was the period of highest risk, with drug-related deaths being particularly prevalent. Of those people who died soon after leaving prison, a high number had committed acquisitive crimes. Data on the deaths of people who died by suicide on release from police detention showed that they were most likely to have been arrested for suspected sex offences.

In our research, for the Howard League, we analysed the paperwork that probation providers complete when an offender dies and identified a distinct defensive tone, especially where media interest was anticipated. Across both pieces of research our documentary analysis and interviews with police officers, prison officers and coroners identified aspects of policy and practice which might contribute to this high mortality rate. Issues of communication were considered key and participants referred to cuts to community provision which constrained their ability to make onward referrals where someone was in need of help.

The key finding, however, was the difficulty in finding relevant data and then, in turn, the realisation that the data that do exist are far from comprehensive. For example, the data we received about deaths of offenders in the community included many gaps. This raises questions about our understanding of the extent of the problem.

Why the neglect?

We have questioned why it is that non-custodial deaths are so neglected. We have narrowed this down to three broad factors: methodological, policy-related and sociological. Identifying causality or a definitive link between a period in police detention or prison custody and a subsequent death is very difficult, especially where one does not have access to coroners’ reports or case records. Moreover, probation staff appear not to update central records once a verdict at inquest is reached, which means that the cause of death is listed as ‘unknown’ in many cases.

In terms of policy, we have identified a lack of duty to investigate such deaths and wonder how far the massive structural changes in probation practice in recent years have compounded the lack of policy on this or contributed to a failure to implement policy. Finally, a sociological view focuses our attention on the ways in which community related issues receive much less attention than custodial ones. This body of work also highlights how institutions are focused on their own problems, leading to what Moore and Hamilton have termed ‘myopic exclusivity’ which means that the ability to ensure that someone is safe after they have left an institution becomes less important.


Overall, our research has shed light on key issues which underpin the high mortality rate upon release into the community after police detention or prison custody or supervision in the community. But the higher level finding, that such deaths appear to be side-lined when compared to deaths in other criminal justice institutions, is the main barrier that we need to overcome.

In order to address the high mortality rate, lack of knowledge, and general neglect, we advocate the creation of an ethic of care which ‘revolves around the moral salience of attending to and meeting the needs of others for whom we take responsibility (as individuals and as a state)’. Such an approach would enable us to understand the true extent of non-custodial deaths more fully, as well as encourage policies which might serve to prevent such deaths in the future.

Jake Phillips is Senior Lecturer in Criminology at Sheffield Hallam University

Loraine Gelsthorpe is Professor of Criminology & Criminal Justice and Director of the Institute of Criminology, University of Cambridge

Nicky Padfield is Professor in Criminal and Penal Justice and Master, Fitzwilliam College, University of Cambridge