Custodial Deaths in India: Causes, Circumstances and the Imperative of Police and Prison Reform

 

Custodial Deaths in India: Causes, Circumstances and the Imperative of Police and Prison Reform

SR Darapuri I.P.S.(Retd)

Introduction

A death in police or judicial custody is one of the most serious violations that can occur within a constitutional democracy. When the State arrests or imprisons a person, it assumes control over that person's liberty and movement. With that power comes a corresponding responsibility to protect the person's life, physical integrity and dignity. A person may be an accused, an undertrial or a convicted prisoner, but incarceration does not extinguish constitutional rights. Article 21 of the Constitution guarantees the right to life and personal liberty to every person, including those in custody.

Custodial death is therefore not merely a medical event or an unfortunate administrative occurrence. It raises fundamental questions about the exercise of State power, police methods, prison administration, accountability and the rule of law. The crucial questions are: How did the person die? What circumstances preceded the death? Was there torture, excessive force, neglect or denial of medical care? Were the authorities truthful about what happened? Was the investigation independent? And what institutional reforms are necessary to prevent similar deaths?

The persistence of custodial deaths demonstrates that India's criminal-justice system still has a serious accountability deficit. The National Human Rights Commission (NHRC) has repeatedly dealt with cases of deaths in both police and judicial custody and has developed detailed procedures concerning their reporting, investigation, post-mortem examination and magisterial inquiry. Custodial death must therefore be understood as a systemic problem rather than merely as the misconduct of an individual officer.

Nature and circumstances of custodial deaths

Custodial deaths do not have a single cause. A person may die because of a pre-existing illness, inadequate medical treatment, suicide, accidental injury, violence by another prisoner, excessive use of force, torture or deliberate killing. It is therefore wrong to presume that every custodial death is necessarily a case of homicide. Equally wrong, however, is to accept the explanation offered by the custodial authorities without an independent and credible investigation.

In police custody, the circumstances that require particular scrutiny include physical assault during interrogation, illegal detention, prolonged questioning, coercive methods, excessive force and denial or delay of medical treatment. The most disturbing cases arise when the police attempt to extract information or confessions through physical or psychological coercion. Such practices are fundamentally incompatible with modern criminal investigation and constitutional government.

The problem is aggravated when a person is informally detained before the formal arrest is recorded. Unrecorded or poorly documented detention creates an accountability gap. It becomes difficult for the family, courts or independent investigators to establish where the person was, who had custody of him or her, what happened during interrogation and when injuries were sustained.

Judicial custody presents somewhat different challenges. Prisoners may die from untreated illnesses, infectious diseases, inadequate healthcare, suicide, violence, overcrowding, poor sanitation or delayed transfer to hospitals. Prison authorities have a continuing obligation to protect the health of prisoners. The fact that a prisoner is under judicial custody does not relieve the State of its duty of care.

The problem of medical neglect

One of the less visible causes of custodial deaths is inadequate or delayed medical treatment. Every person entering prison should receive a proper medical examination. Existing illnesses should be recorded, medicines continued, and persons requiring specialist treatment should be referred promptly to appropriate hospitals.

When a prisoner complains of chest pain, breathing difficulty, severe injury, neurological symptoms, mental distress or other serious symptoms, prison authorities cannot simply assume that the complaint is minor. Delay in treatment can turn a treatable illness into a fatal emergency.

Consequently, investigation of a custodial death must examine not merely the final medical cause of death but the entire history of medical care: the initial examination, complaints made by the prisoner, medicines provided, medical consultations, hospital referrals and emergency response.

Custodial violence and torture

The most serious category of custodial death is death resulting from alleged torture or unlawful violence.

Torture is sometimes rationalised as an investigative technique, particularly where police officers are under pressure to solve crimes quickly. Such thinking is fundamentally flawed. A confession obtained through violence is not a substitute for scientific investigation. Modern policing should rely upon forensic evidence, DNA, fingerprints, digital evidence, financial investigation, crime-scene analysis and professionally conducted interviews.

The continued use of coercion reflects an institutional culture in which the police may be judged more by arrests, recoveries and confessions than by the quality and legality of investigation.

The answer cannot simply be to instruct individual officers not to torture. There must be institutional mechanisms capable of detecting and punishing torture and creating incentives for lawful investigation.

The culture of impunity

The greatest danger surrounding custodial deaths is the possibility of impunity.

The institution responsible for the custody often controls the first account of the death, the custody records, the police diary, CCTV footage, medical records and witnesses. Where the same institution is also allowed to conduct the initial investigation, there is an obvious conflict of interest.

A credible investigation must therefore be independent, impartial, prompt and transparent.

The Supreme Court has repeatedly emphasised this principle. In D.K. Basu v. State of West Bengal, the Court laid down safeguards intended to protect persons during arrest and detention and recognised custodial violence as a serious violation of constitutional values. In Nilabati Behera v. State of Orissa, the Court affirmed the availability of compensation as a public-law remedy for violation of the fundamental right to life.

These judgments establish an important constitutional proposition: custody increases the State's responsibility; it does not reduce the citizen's rights.

The importance of an independent post-mortem

A proper medico-legal post-mortem is indispensable in every custodial death. It should not be treated as a routine administrative formality.

The examination should document every external injury, however apparently insignificant, and should include an appropriate internal examination. Bruises, abrasions, swelling, lacerations, ligature marks, burns, restraint injuries and injuries to the head, neck, back and limbs should be carefully recorded.

Photographs should be taken and, where required under the applicable NHRC guidelines, the examination should be videographed. Appropriate biological samples and viscera should be preserved and sent for forensic examination.

The body and clothing should be protected from unnecessary interference before forensic evidence has been collected. The chain of custody of all samples must be maintained.

The post-mortem report should provide sufficient factual detail to allow an independent expert or court to determine whether the medical evidence is consistent with the official account of death.

Preservation of CCTV and other evidence

Technology can play an important role in preventing custodial abuse and establishing the truth after death.

CCTV cameras should function continuously in police stations and prisons, subject to legitimate privacy requirements. The system should have secure storage that prevents manipulation or selective deletion.

When a custodial death occurs, the relevant CCTV footage should immediately be preserved. A disappearance of footage, unexplained technical failure or gap during the critical period should itself become a matter of investigation.

Other important evidence includes arrest and detention records, general diary entries, duty rosters, interrogation records, medical records, hospital records, visitor registers, transport records and statements of fellow detainees or prisoners.

Magisterial inquiry and NHRC oversight

The law requires special scrutiny of custodial deaths. Under the Bharatiya Nagarik Suraksha Sanhita, 2023, a Magistrate conducts the prescribed inquiry into deaths occurring in custody. This is an important safeguard because the investigation should not remain exclusively within the police hierarchy.

The NHRC also requires custodial deaths to be reported within the prescribed period and has developed detailed guidelines for post-mortem examination, videography, magisterial inquiry and submission of investigation reports.

The purpose of these mechanisms is to prevent custodial death from becoming an internal administrative matter. The death of a person in State custody is a matter of public concern because it directly implicates the exercise of State power.

The special responsibility of prison authorities

Prison administration must be based upon the principle that imprisonment means deprivation of liberty, not deprivation of dignity.

Prisoners should receive adequate food, clean water, sanitation, healthcare and protection from violence. Every prisoner should undergo medical screening on admission. Vulnerable prisoners—including elderly persons, persons with serious illnesses, persons with disabilities and those at risk of suicide—require additional protection.

Mental health deserves particular attention. Prisoners may experience isolation, fear, depression, family separation and uncertainty about their cases. Suicide-prevention systems, psychological counselling and trained prison staff are therefore essential.

Overcrowding also places enormous pressure on prison administration and healthcare. Reducing unnecessary pre-trial detention is therefore not merely a judicial reform but also an important prison-health measure.

The Uttar Pradesh dimension

The problem deserves particular attention in Uttar Pradesh because of the enormous size of its criminal-justice and prison system. NHRC data have repeatedly recorded substantial numbers of judicial-custody deaths in the State (2630 Between 2016 and 2022).

Recent NHRC interventions demonstrate that custodial deaths continue to require scrutiny. In cases involving alleged police violence, the Commission has sought arrest records, medical-legal certificates, general diary entries, post-mortem reports, videography, forensic reports and magisterial inquiry reports.

The lesson for Uttar Pradesh is that custodial deaths should not be handled merely as isolated incidents. There should be a systematic State-wide mechanism for prevention, investigation and public accountability.

Every district should maintain a custodial-death monitoring system involving the district administration, prison authorities, police leadership, health officials and independent human-rights institutions. District-wise information should be periodically reviewed to identify patterns and recurring institutional failures.

Making investigation genuinely independent

One of the most important reforms is to ensure that police personnel accused of custodial violence are not allowed to investigate themselves.

Where the circumstances warrant it, investigation should be transferred to an independent specialised unit or another legally competent agency. In particularly serious cases, judicial monitoring may be necessary.

The principle should be clear:

No institution should be the sole investigator of serious wrongdoing allegedly committed by its own personnel.

Independence must also extend to forensic medicine. Doctors conducting post-mortems should be protected from police or administrative pressure. Their professional duty is to record medical facts objectively, irrespective of the interests of the custodial authorities.

Accountability must extend to senior officers

Custodial death should not result merely in the suspension or prosecution of a subordinate officer while the supervisory structure escapes scrutiny.

Whenever evidence indicates that senior officers knew about abusive practices, ignored complaints, failed to supervise personnel, suppressed evidence or failed to provide medical care, their responsibility should also be examined.

Accountability must therefore operate at three levels:

individual responsibility, for the officer who committed the unlawful act;

supervisory responsibility, where senior officers failed to prevent or respond to misconduct; and

institutional responsibility, where systemic practices created conditions conducive to custodial violence or neglect.

Compensation and justice for families

The family of a person who dies in custody often faces not only grief but also economic hardship and an unequal struggle against State institutions.

Where a violation of fundamental rights is established, compensation should be available through appropriate legal mechanisms. The Supreme Court's jurisprudence recognises compensation as a public-law remedy in appropriate custodial-death cases.

But compensation cannot replace criminal accountability. A State cannot effectively say that a person's life can be valued in money and the matter thereby closed. Where criminal conduct is established, prosecution must follow.

The family should also have meaningful access to post-mortem reports, medical records, forensic reports and the findings of the magisterial inquiry, subject to legitimate legal restrictions.

From confession-oriented policing to evidence-based policing

Long-term prevention requires transformation of the police organisation itself.

India needs to move decisively from confession-oriented policing to evidence-oriented investigation.

The modern investigator should be trained in: forensic science; DNA analysis; cyber-forensics; digital evidence; financial investigation; crime-scene management; professional interviewing; behavioural analysis; witness protection and human-rights law.

The quality of policing should be measured by the quality and legality of investigation, not merely by the number of arrests or confessions.

Training must therefore be combined with institutional incentives and strong disciplinary mechanisms.

Towards a people's police

The deeper question is what kind of police force a democratic society requires.

A colonial police culture was fundamentally concerned with maintaining authority and controlling the population. A constitutional democracy requires a different philosophy: the police must be accountable to the law and serve the citizen rather than treat the citizen as an object of control.

The transformation from a colonial police mentality to a constitutional police culture requires respect for dignity, equality, fraternity, due process and accountability.

This is also consistent with Dr. B.R. Ambedkar's conception of constitutional democracy. Democracy is not merely a mechanism for electing governments; it requires constitutional morality, equality and respect for the dignity of every individual. The treatment of a powerless person in custody is therefore one of the clearest tests of constitutional morality.

A comprehensive reform agenda

India needs a national custodial-death prevention framework based on the following principles:

1.     Immediate and mandatory reporting of every custodial death.

2.     Independent magisterial inquiry in accordance with law.

3.     Independent medico-legal post-mortem in every custodial death.

4.     Mandatory photography and appropriate videography of post-mortem examinations.

5.     Immediate preservation of CCTV footage and electronic evidence.

6.     Independent investigation wherever custodial personnel are implicated.

7.     Mandatory medical examination at entry into police and prison custody.

8.     Continuous healthcare and emergency hospital referral for prisoners.

9.     Independent prison inspections and regular human-rights audits.

10. Protection of complainants, witnesses and families from intimidation.

11. Transparent publication of custodial-death statistics and outcomes.

12. Criminal and departmental action where wrongdoing is established.

13. Compensation and effective legal remedies for victims' families.

14. Professional, forensic and evidence-based police investigation.

15. Human-rights and constitutional-morality training for police and prison personnel.

16. Accountability of supervisory officers where negligence or deliberate concealment is established.

Conclusion

Custodial death is not merely the death of an individual. It is a test of the State's commitment to the Constitution.

A democratic government has legitimate authority to arrest, detain and imprison people according to law. But the exercise of coercive power carries with it an even greater obligation to protect those placed under State control.

The essential principle should therefore be uncompromising:

The State may deprive a person of liberty according to law, but it cannot deprive that person of dignity or life through arbitrary, unlawful or excessive exercise of power.

The credibility of Indian democracy will ultimately depend on whether the police station and prison remain spaces where constitutional rights continue to operate or become spaces where those rights disappear.

The objective must be to transform the system from custodial power to custodial accountability, from coercion to investigation, from secrecy to transparency, and from impunity to the rule of law.

A truly democratic police force is not one that merely controls people effectively. It is one that can exercise power without fear, without favour and without brutality—and remain fully accountable when that power is abused.