Death in Custody

In the United States, every state has some requirement for deaths in custody to be investigated by a coroner or medical examiner (C/ME). In the Commonwealth of Pennsylvania, for example, coroners must investigate: “a death occurring in prison or a penal institution or while in the custody of the police …for the purpose of purpose of determining whether or not an autopsy or inquest should be conducted (PA 16 P.S. § 1218-B).

Why should the Coroner Investigate?

The C/ME investigation determines the cause and manner of death when someone dies in custody. The independence of C/MEs in these investigations is essential. Often District Attorneys or other prosecutorial agencies also investigate deaths in custody. Their findings, however, may not be accepted by family or the public because these agencies are perceived to have close ties to law enforcement. That’s why C/MEs should have full control over their own investigation into the cause and manner of in-custody deaths. The results of their investigation should be public. Coroner inquests for deaths in custody are making a comeback because of this need for transparency. In other English common-law countries, including England, public Coroner’s Inquests are required for in-custody deaths.

Unfortunately, there are few truly independent coroners or medical examiners in the United States. An extreme example is California, where the sheriff is often also the coroner. Because of several controversial in-custody deaths and under-reporting of such deaths there, a movement is underway to separate the two functions.

What is a Death in Custody?

What counts as a death in custody? There are two broad categories. One is deaths of people in jail or prison. The other is any death that happens when police interact with a person outside of prison or jail. This post discusses only in-custody deaths occurring outside of prison or jail – we’ve all seen them captured on video.

The media has publicized many in-custody deaths, especially since the death of Michael Brown in Ferguson, MO. In fact, the media and other non-governmental sources may provide the most accurate accounting of how many such deaths occur. The Washington Post, for example, has maintained a database of fatal shootings by police since 2015. At the end of June 2022, over 5,000 such deaths had been recorded.

Reporting is Unreliable

Official governmental sources grossly under-report deaths in custody. That includes The Death in Custody Reporting Act (DCRA) of 2013 (P.L. 106-297) database. The US Department of Justice (DOJ) acknowledges problems with its implementation. Another government source is the CDC’s National Vital Statistics System (NVSS). It is incomplete and inaccurate due to problems with death certification.

Medicolegal death investigators play a critical role in reporting deaths in custody by what they put on a death certificate. Only C/MEs complete those death certificates. Therefore the problems with the NVSS are due at least in part to incomplete or inaccurate death certificates by coroners and medical examiners.

How to report a death in custody on the death certificate

How can coroners and medical examiners improve the NVSS? Include terms like “legal intervention” or “injuries inflicted by police” as the underlying cause of death. Use the injury section to explain what happened using phrases like “killed by police” if that’s what happened. This includes “suicide by cop” cases and deaths other than shootings. The folks that code death certificate language for CDC won’t count it as an in-custody death unless C/MEs tell them that’s what it was. The National Association for Medical Examiners (NAME) has published a position paper with recommendations on deaths-in-custody.

There’s a simpler fix that’s in the hands of state policy makers: add a death in custody checkbox to the death certificate. Dr. Roger Mitchell, former Washington, D.C. medical examiner and co-author of the NAME position paper and an upcoming book Death in Custody, is a strong advocate of this approach. In Pennsylvania, lawmakers added five different pregnancy status boxes in 2012. Checkboxes for race and ethnicity have proliferated since 2013. Why not add one simple checkbox- death in custody, yes or no?

Note: This post was updated on February 19, 2023.