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.