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Procedure Properties

Title: Death in Custody
Category: Custodial Operations - Standard Operating Procedures
Version: 01
Implement Date: 19 April 2012
Application: Custodial Operations
Availability: Public


Appendices and Forms

Associated Custodial Operations Standard Operating Procedures

Local Procedures

QCSA Training Manual

Agency Procedures


Review Date: 2014

Ownership: Custodial Operations

Custodial Operations Standard Operating Procedure - Death in Custody

Performance Standard
1.Procedure Requirements
2.Provision of Health Services
3.Access of Supporting Agencies to a Facility
5.Notification Requirements for a Death in Custody
5.1Legislative requirements
5.2Notification of a prisoner's nominated contact person
5.3Media notification
5.4Where prisoner is a foreign national
6.Burial Assistance Scheme
7.Removal of the Body
8.Recording of Events
10.Record of Deceased Prisoner
12.Release of Deceased Prisoner's Property

Performance Standard

A death of a prisoner in custody is immediately responded to, reported in a professional and sensitive manner and treated according to legislative and procedural requirements. This is undertaken with regard to the rights and obligations of members of the community, other public officials and the prisoner. This completed in accordance with-

Safety & Security - Our Principles

Refer - Safety and Security - Our Principles (in-confidence).


Corrective Services Act 2006, ss. 24, 265, 295

Corrective Services Regulation 2006, s. 21

1. Procedure Requirements

The death of a prisoner in custody must be managed with integrity and respect for the deceased.

Every effort must be made to save life exclusive to any other consideration including preservation of a crime scene and evidence. The crime scene and evidence must be preserved within the limits of the efforts being made to save life.

The responsibilities of officers managing a death in custody in a corrective services facility include compliance with procedures-

  1. First Officer Response - Medical and Assault; and
  2. Preservation of a Crime Scene and Evidence.

Standard precautions must be utilised in dealing with any body secretions. Refer standard operating procedure - Standard Precautions - Infection Control and Hygiene Management

All deaths in custody are subject to a coronial inquiry and will be reported to the Coroner by staff of the Queensland Police Service.

1.1 Definitions

corrective services facility means-

  1. a prison; or
  2. a community corrections centre; or
  3. a work camp.

prison means a place declared to be a prison under section


Refer CSA Schedule 4

S 149 Prisons

A regulation may-

1. declare a place to be a prison; and

2. assign a name to a prison.

Refer CSA s 149

The area declared to be a prison for each corrective services facility is outlined in the CSR -Schedule Prisons.

Prisoner includes a person who, immediately before the person's death, was a prisoner, but does not include a prisoner released on parole, refer CSA, s 24(3) (note that this definition of prisoner only applies to for the purposes of CSA, s 24 ).

2. Provision of Health Services

Until otherwise advised by Queensland Health staff, officers must treat an apparent death in custody as a medical emergency and commence all life-saving measures.

If Queensland Health centre staff are on duty, they must be called urgently. If health staff are not on duty ambulance assistance must be sought urgently by dialling 000.

Once commenced, resuscitation must continue until otherwise instructed by a doctor, paramedic or registered nurse.

The declaration of life extinct must be made by either the attending medical officer, Queensland Ambulance Officer or a registered nurse employed to work in a Queensland Health centre under special authority given by the Queensland Health Chief Health Officer.

Refer Offender Health Service procedure - Death in Custody

3. Access of Supporting Agencies to a Facility

Provision must be made for rapid and easy access to a facility for support agencies responding to the incident that may include, but are not restricted to-

  1. ambulance and paramedic teams;
  2. visiting doctor;
  3. Coroner;
  4. a religious visitor;
  5. an Aboriginal or Torres Strait Islander Legal Service representative;
  6. an elder, respected person or indigenous spiritual healer who is relevant to the prisoner;
  7. Corrective Services Investigation Unit (CSIU) officers;
  8. police officers;
  9. morgue, funeral home/under taker representatives;
  10. corrective services dogs and their handlers;
  11. counselling service providers.

Officers controlling access to a facility should be aware that the ambulance service might respond with two vehicles-

  1. an ambulance transport vehicle; and
  2. a paramedic medevac vehicle.

The ambulance officers attending must supply a job number and provide their identification details.

4. Reporting

A critical incident report of the death in custody of a prisoner must comply with standard operating procedure - Incident Reporting.

5. Notification Requirements for a Death in Custody

5.1 Legislative requirements

After a prisoner dies, the general manager or nominee if the corrective services facility must notify each of the following that the prisoner has died-

  1. if the corrective services facility is a prison-a doctor appointed for the facility;
  2. the police officer in charge of the police station nearest to the place where the prisoner died;
  3. the person nominated by the prisoner as the prisoner's contact person;
  4. a religious visitor;
  5. for an Aboriginal or Torres Strait Islander prisoner-

1. an Aboriginal or Torres Strait Islander legal service representing Aboriginal or Torres Strait Islander persons in the area in which the prisoner died; and

2. if practicable, an elder, respected person or indigenous spiritual healer who was relevant to the prisoner.

Refer - CSA, s 24(1)

5.2 Notification of a prisoner's nominated contact person

Notification to a deceased prisoner's nominated contact person should be made as soon as possible after death has been established, subject to operational requirements.

Officers responsible for notifying a deceased prisoner's contact person should approach the task bearing in mind how they themselves would like to be notified in similar circumstances. It should also be borne in mind that the person nominated by the prisoner as a contact person may not be the offender's next of kin.

Notification to a deceased prisoner's contact person must be given in a sensitive fashion respecting the culture and interests of the person and the entitlement of such person to knowledge of the facts about the death, other than any matter that is the subject of police investigation, that are known at the time of notification. Speculative or unsubstantiated details of the death are not to be given to the prisoner's contact person.

The general manager or nominee of the facility must notify the prisoner's contact person-

  1. in the case of the death of an Aboriginal or Torres Strait Islander prisoner-if practicable, in the company of an elder, respected person or indigenous spiritual healer who is relevant to the prisoner; or
  2. otherwise-if practicable, in the company of a relative of the bereaved, a support person or a religious visitor.

If the deceased prisoner's contact person is located in a rural area of Queensland or interstate, the local police in that area or State must be requested, through the CSIU, to make the notification.

If the deceased prisoner's contact person cannot be located assistance should be sought from CSIU.

The person providing notification should, if circumstances warrant it, render assistance to the bereaved in contacting other members of the deceased prisoner's family and provide any other assistance deemed appropriate using, if necessary, the services of other staff or a religious visitor. For example, if the deceased prisoner's contact person is a prisoner in the same or another Queensland corrective services facility, assistance could be provided in contacting other relatives and making funeral arrangements.

Every effort must be made to identify a deceased prisoner's next of kin and, if practicable, also notify that person of the prisoner's death.

5.3 Media notification

The Director of the Office of the Commissioner is responsible for establishing with the appropriate General Manager or duty executive if next of kin have been informed before releasing information to the media. If the next of kin have not been informed, no information that is likely to enable those persons to identify the deceased prisoner should be released to the media. A notification to the media about a death in custody may only be made by the Director of the Office of the Commissioner.

5.4 Where prisoner is a foreign national

If the prisoner is identified as a foreign national, refer Detention Or Death of a Foreign National In Australia.

6. Burial Assistance Scheme

The notifying officer should, having regard to the deceased prisoner's family's circumstances, provide information regarding assistance available for burial or cremation of the deceased prisoner. The bereaved may be advised that assistance is available from-

  1. in Brisbane-

    Coronial Unit
    Department of Justice and Attorney-General
    Phone: (07) 3239 6193 or 1300 304 605

  2. elsewhere-the local Magistrates Court.

More details may be obtained from the Department of Justice and Attorney-General website at

There is no provision for the Department of Justice and Attorney-General to subsidise funerals or to reimburse money already paid for a funeral. If the deceased prisoner's family wishes to claim assistance the claim must be made in the first instance and a contract should not be entered into with a funeral home. This information must be made clear to the deceased prisoner's next-of-kin at the time of notification of death and file-noted.

7. Removal of the Body

The body of a deceased prisoner must not be moved from the scene of death until an officer of the CSIU has provided authorisation for the removal and a doctor or registered nurse has certified the Notification of Life Extinct.

The body must only be removed from the facility after a doctor or registered nurse has given authorisation to do so. A receipt for the body must be provided to the general manager of the facility by the agency removing the body at the time of removal (refer administrative form - Transfer of Custody of Body to Queensland Police Service).

8. Recording of Events

If possible the recording of events should be completed by the first officer responding to the incident and include the-

  1. time the deceased was found;
  2. location of the body when found;
  3. circumstances under which the body was found;
  4. description of the scene where the body was found;
  5. description of any weapon or other device found at the scene;
  6. names of offenders at the scene when the deceased was found;
  7. names of other staff who assisted in managing the incident;
  8. names of any witnesses to the incident; and
  9. times of attendance and identity of all persons attending the scene.

If possible, an electronic record should be kept of all entry to the scene and all life-saving attempts.

9. Documentation

If possible, a copy of the following documentation must be provided for investigation management-

  1. a print out of a complete profile of the deceased from the Intelligence Profile Data Base;
  2. the Offender File;
  3. print outs of all information that can be extracted from IOMS including Incident and Breach Information, Immediate Risk Needs Assessments, Risk Assessment Team documentation and Sentence Management Reviews;
  4. any Psychological or Detention Unit notes or files kept separately from the Offender File;
  5. the Notification of Life Extinct certificate; and
  6. any other documentation or reports relevant to the incident including initial Officer Statements and Memos, Running Logs, Nominal Rolls, Arunta Phone Records, tapes of phone conversations, Debrief Minutes and Movement Logs.

A record of what documentation has been provided and to whom must be kept and, if original documentation has been provided, receipts obtained.

10. Record of Deceased Prisoner

The general manager or nominee of a corrective services facility must keep a record of the details of a deceased prisoner in accordance with CSA, s 24 and Corrective Services Regulation 2006, s 21.

11. Debriefing

Following a death in custody debriefing of persons involved must include, but is not limited to-

  1. critical incident stress debriefing for all staff involved in the incident. Refer procedure - Managing Traumatic Events at Work;
  2. an operational debrief, facilitated by the relevant manager, for all staff involved in the management of the incident;
  3. the services of counselling through a preferred service provider is to be offered to all staff involved in the incident (the circumstances relating to the incident are to be provided to the counselling provider by the general manager or nominee);
  4. appropriate access to a counsellor for prisoners who either experienced the incident or who had significant contact with the deceased offender; and
  5. if relevant, an appropriate Aboriginal or Torres Strait Islander organisation should be involved in the debriefing.

It is important to note that operational debriefing or counselling should not commence until such time as the police have interviewed the staff or prisoners directly involved in the incident. This will ensure that the process of an investigation by police is not compromised. Minutes from operational debriefs should be provided to the inspectors conducting the internal departmental investigation.

12. Release of Deceased Prisoner's Property

Refer standard operating procedure - Property of Prisoners

13. Investigations

An investigation, other than a criminal investigation, must be undertaken for all incidents of death of a prisoner.

If the death is other than by apparent natural causes inspectors must be appointed under CSA s 295 to investigate the incident.

If the death is by apparent natural causes either-

  1. inspectors must be appointed under CSA s 295 to investigate the incident; or
  2. a person/s, nominated by the person responsible for incident investigation or the relevant executive director, must be assigned to investigate the incident.

Without limiting the scope of an investigation an examination must be made to establish compliance with this standard operating procedure.

Endorsed by:


Acting Deputy Commissioner, Custodial Operations

Approved by:


Version History

19/04/2011 Version 01