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Custody deaths (Angiolini report) Deaths and serious incidents in police custody

The 2017 Angiolini Review was an independent, non-statutory investigation into systemic failures surrounding deaths in police custody, highlighting that restraint should be treated as a medical emergency rather than just a use-of-force issue.

The review was commissioned by Theresa May (during her time as Home Secretary) following high-profile deaths such as those of Sean Rigg and Olaseni Lewis. It was led by Dame Elish Angiolini, a former Solicitor General for Scotland.


While the actual investigation and writing of the report took roughly 15 months (Oct 2015 – Jan 2017), there was a significant 10-month gap between the report being finished and the government actually publishing it.


This delay was a major point of criticism at the time. The Home Office was accused of "sitting on the report," with campaigners and families of those who died in custody (like the family of Sean Rigg) demanding its release. The government eventually published it alongside their official response in late October 2017.


Key Findings and Themes

The report was exhaustive, featuring 110 recommendations aimed at overhauling how the police, health authorities, and the justice system handle vulnerable people. Its primary focus areas included:


  • Restraint and Force: The report argued that police must treat all restraint—especially against those in mental health crisis—as potentially life-threatening. It called for the phasing out of police cells as a "place of safety" for those suffering from mental illness.


  • Race and Ethnicity: It highlighted the disproportionate use of force against Black, Asian, and Minority Ethnic (BAME) individuals and called for investigators to explicitly consider whether discriminatory attitudes played a role in restraint-related deaths.


  • Treatment of Families: A central theme was the "callous" treatment of bereaved families. Angiolini recommended that families receive non-means-tested legal aid for inquests to level the playing field against well-funded police legal teams.


  • Accountability: The report criticized the "lack of real accountability" and recommended that officers involved in a death be separated immediately to prevent them from "conferring" before giving their initial statements.


Impact and Progress

While the report was hailed as a "blueprint for change" by the campaign group INQUEST, its implementation has been a point of contention:

  • Legal Aid: The government initially rejected the recommendation for automatic, non-means-tested legal aid for families, though some adjustments to the "means test" were later made to reduce the burden on the bereaved.

  • Mental Health: There has been a push to move mental health crises away from police custody (e.g., through "Street Triage" schemes), but many critics argue the progress has been too slow.


  • Persistence of Issues: In a 2021 progress update, campaigners noted that the number of deaths following police contact remained largely unchanged, leading Dame Angiolini herself to remark at one point that some recommendations had been "kicked into the long grass."


While described as the first, it was merely one of the highest profile amongst a long series of inquiries in to deaths and poor treatment in custody including

The Waters tribunal

The Harris inquiry

Bernard Lodge inquiry

The Butler report


Note: Dame Elish Angiolini also recently led the Angiolini Inquiry (Part 1) into the abduction, rape, and murder of Sarah Everard, which was published in February 2024. This is a separate, though related, investigation into police vetting and culture.

Key numbers at a glance

110

Recommendations

24

Months to complete

​

Cost in millions      (if known)

​

Deaths (direct)

Recommendations

The key findings can be summarized into four primary pillars:


1. Policing and Mental Health

The report found that police officers were too often acting as "first responders" to mental health crises for which they were not trained.

  • Cells are not "Places of Safety": It recommended that police cells should never be used as a place of safety for those in mental health crisis under the Mental Health Act.

  • Medical Emergency: It argued that any struggle involving restraint should be treated as a medical emergency, as deaths in custody are often linked to "excited delirium" or acute behavioural disturbance.


2. Use of Force and Restraint

The review was highly critical of dangerous restraint techniques.

  • Prone Restraint: It called for a ban on dangerous restraint positions (like face-down/prone restraint) that can lead to positional asphyxia.

  • Institutional Memory: It noted a failure to learn from previous deaths, with similar mistakes regarding force being repeated over decades.


3. Racial Disproportionality

Angiolini addressed the "disproportionate number of deaths" of people from Black and Minority Ethnic (BAME) communities following the use of force.

  • Stereotyping: The report identified that "dangerous" stereotypes often led to a more aggressive police response toward BAME individuals.

  • Implicit Bias: It recommended that investigators (the IOPC) should explicitly examine whether racial discrimination or unconscious bias played a role in any death involving restraint.


4. Accountability and Treatment of Families

Perhaps the most emotive part of the report was its focus on the "cruel" experience of bereaved families.

  • Legal Inequality: Families often faced "hostile" inquests where police were represented by top-tier lawyers funded by the taxpayer, while families had to fight for Legal Aid. Angiolini recommended automatic, non-means-tested legal aid for families.

  • Officer "Conferring": To ensure transparency, the report stated that officers involved in a death should be separated and prohibited from speaking to each other before providing their initial accounts, preventing them from "aligning" their stories.


Summary Verdict

The overarching finding was that the system for investigating deaths in custody was defensive, slow, and lacked true accountability, often prioritizing the protection of police reputations over the rights of the deceased and their families.

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