The Police Chief, the Professional Voice of Law Enforcement
Advanced Search
September 2016HomeSite MapContact UsFAQsSubscribe/Renew/UpdateIACP

Current Issue
Search Archives
Web-Only Articles
About Police Chief
Law Enforcement Jobs
buyers Your Oppinion

Back to Archives | Back to January 2004 Contents 

Investigator Protocol: Sudden In-Custody Death

Chris Lawrence, Team Leader, Defensive Tactics Training Section, Ontario Police College, Aylmer, Ontario, Canada, and Wanda K. Mohr, Associate Professor, Psychiatric Mental Health Nursing, University of Medicine and Dentistry of New Jersey, Newark, New Jersey

A man witnesses said possessed "superhuman strength" collapsed and died Tuesday in the wake of a battle with police.

One witness told the Daily Press the man was "tossing police like they were small children" when they tried to subdue him in a neighborhood park.

Five officers responded to a 2 p.m. call that the man, described as five feet nine inches tall and weighing 190 pounds, was running naked through the streets breaking windows.

Attempting to take him into custody under the Mental Health Act, the officers, witnesses said, were threatened frequently with bodily harm.

Officers surrounded the man in an open area, next to the Locust Park shopping plaza, and were unable to get him to cooperate.

When the man attempted to flee, a struggle ensued. Officers reported they had "great difficulty" containing him.

Shortly after they subdued the man, the officers found him to be unresponsive. They rushed him to nearby Parkside Hospital, where efforts to revive him were unsuccessful.

When the coroner's office released the results of the subsequent autopsy, the report stated there was no obvious cause of death. There were no lethal levels of cocaine or alcohol and, despite the man's history of mental illness, he was not taking any medication in the days prior to his death.

Because there were insufficient findings to account for the man's death the case was turned over to police for investigation. All five officers involved in the incident were suspended, with pay, pending the investigation.

A spokesman for the dead man's family said an attorney has been retained with an eye toward a wrongful death lawsuit against the police officers and department.

A television editorial comment last night on WZAB accused the coroner's offices of incompetence and the police department of brutality.

Scenarios like this one can have numerous negative consequences, including financial ones, for everyone involved, from the police officers who are suspended and investigated to the employees of the medical examiner's office to the victim's family. Nothing good comes from such incidents, which may be unavoidable.
The reasons for sudden death in custody are multifactoral and complex. Fortunately, careful police work can help mitigate the negative fallout. In this article we describe an investigative protocol for sudden in-custody deaths. At times, professionals following traditional protocol find it difficult or impossible to establish an obvious mechanism of death. They may be overlooking valuable information that is not part of a standard investigation but that can nevertheless assist medical examiners and investigators.

Incidents involving subjects who die suddenly and unexpectedly while in custody fit two profiles. Investigators find that subjects die from conditions that leave evidence readily apparent at autopsy (such as heart attack, aneurysm, or stroke) or they find insufficient evidence to establish a cause of death. The first profile is generally unproblematic and the case is closed. The second instance is a significant problem and calls for intensive investigation.

When professionals can establish no obvious mechanism of death after pursuing all the routine elements of a competent investigation, detectives can scaffold their investigation through a protocol that is informed by several bodies of research. The first, and perhaps most common, is the psychiatric research. Psychiatric illness and substance abuse figure prominently in many instances of sudden in-custody death. Given this knowledge, investigators should examine subject's personal history, the nature of the custody incident, and the environmental factors surrounding the incident.

Subject's Personal History
Investigators know that attention to detail is a critical component of police work. The often dry details of a person's history may provide answers to questions surrounding a sudden in-custody death. Some of the necessary questions described below may be obvious to an experienced professional, but what may be surprising to some is how the answers can provide important clues.

Residential History: The first category of information involves documenting the subject's actual street address and apartment number throughout his or her life. Such a history includes documenting the current residence and working backward. This level of detail enables investigators to track all past health issues, treatment, and medication to which the subject might have been exposed.

Educational History: Once investigators know a subject's lifetime residential history, they can contact school districts to gather important data. School records can yield clues suggestive of maladaptation. Important questions include the following: Was the subject prone to outbursts or violence as a child? Did he or she have a history of maltreatment, including physical and sexual abuse or neglect? Was he or she involved in special needs education? Were there any reports of major traumata such as the death of a parent, out-of-home placement, or major illnesses or surgeries? Are there gaps in the school record suggestive of significant time away from school? Is there a history of truancy? Questions concerning any medically suspicious events, such as fainting spells, frequent accidents, or incidents suggestive of substance abuse, can yield important investigatory information.

Family History: School personnel and neighbors can sometimes provide clues to the subject's family life. A subject's family history can yield rich data about the genetic and environmental influences. Questions in this category include the following: Was there a history of domestic violence or other domestic disturbance that might indicate drug or alcohol use or abuse? Was there a family history of mental illness? Was there a history of illnesses sometimes associated with sudden death, such as cardiovascular problems? Was there a history of drug or alcohol abuse? Were there other major stressors in the subject's life as he or she grew up?

Employment History: Because occupational functioning is an important indicator of psychological adaptation, employment history can provide clues to the presence of psychiatric difficulties or to patterns of interpersonal conflict or violence. Questions investigators might ask include the following: Did the subject have a history of any behavioral problems at work or during any military service? Are there long gaps in his or her employment record, indicating hospitalization or incarceration? An examination of health insurance records may offer information about prescription medications and duration of use.

Financial History: Financial status can be an important indicator of stability or, conversely, high stress and the presence of mental illness. For example, unusual patterns of bank activity, such as sudden withdrawals of large amounts of money may be associated with a manic condition. In addition, civil suits, bankruptcies, large unserviced debts, active collections, or other financial difficulties can serve as intense stressors that might exacerbate pre-existing psychiatric disorder. Careful investigation of the subject's financial history can bring these stressors to light.

Police Contact History: A history of psychiatric illness, substance abuse, or violent behavior can be reflected in the subject's appearance in police databases. A prudent review of not only local records but also records in every other jurisdiction where the subject has lived or worked can add to the overall picture. Was the subject arrested for or charged with any misdemeanor or felony? Was there a history of domestic violence or disturbance calls to his or her address? Was there a history of drunk driving? Probation history, presentencing reports, and court-ordered psychiatric assessments may also reveal valuable information.

Medical History: The medical examiner's office will be helped in its determinations by investigators' inquiries that point to histories of acute or chronic illnesses and past medical treatment. If possible, the investigator should check the subject's family medical history as well. These queries may reveal a family history of risk factors that might not have been observed in the subject but that nevertheless may have put the subject at risk for sudden death. An example might be a family history of early sudden death.

A list of current prescription medications and over-the-counter drug purchases can provide clues, as many medications can be implicated in sudden death. The residence should be searched to locate all medications the subject may have taken, either intentionally or inadvertently. Medication information should include the name of the drug on the prescription label, date of the prescription, amount dispensed, and amount remaining. The latter is important, as the subject may have stopped using his or her medication or may have taken too much. Searching for medication history can also provide information about a history of drug or alcohol abuse, duration of the abuse, evidence of cessation, and duration of abstinence.

In addition to a search of medicine cabinets, the investigation should include a search for recent medically related purchases, health plan records, local pharmacy records and physician records for clues as to the subject's state of physical and mental health. This information is particularly relevant in the months before the incident occurred, because it may indicate a change from a usual state of functioning. In order to determine possible inadvertent or purposeful overdose, investigators should look for evidence of so-called double doctoring: receiving care from many physicians but failing to inform each caregiver of the prescriptions written by others, thereby subjecting oneself to possible toxic interactions between drugs or between drugs and certain foods. For example, grapefruit juice, certain cheeses, aged meat, draft beer, and red wine can interact severely with certain psychotropic medications. In addition, people who seek contact with many physicians may do so because they are abusing multiple prescription medications.

An important condition to determine is whether the subject is diabetic. Diabetics can decline from a physiological standpoint—quickly and fatally—if they fail to match their food intake and insulin levels. Other conditions that might inform further investigation of agitated, hyperventilating, rigid, or uncooperative victims are such ailments as asthma, psychotic hallucinations, epilepsy, and acute mania.

Once investigators have collected information concerning all medications and substances of abuse the subject may have ingested, they should consult a clinical toxicologist or a pharmacist. In some jurisdictions, toxicologists, who are trained chemists, have been involved in this type of an investigation in order to determine whether the levels of a particular substance found in the body are toxic. However, a pharmacist or clinical toxicologist, who is physician-trained, can advise on issues such as drug interactions and the documented side effects of prescribed medications, over-the-counter drugs, and substances of abuse, as well as inform in the areas of drug and food interactions. When seeking the services of clinical toxicologists or pharmacists, teaching hospitals where psychiatry and cardiology are practice specialties would be a good place to start. These specialists can prove most valuable in investigations of this kind.

Nutritional History: A recent nutritional history that looks at factors such as what the subject had to eat that day as well as whether he or she had any marked changes in his or her eating habits in the several weeks before the custody incident can provide important clues. If he or she was in a crisis state or decompensated physically or mentally, the subject may not have been eating for some time. In addition, behaviors such as polydipsia, a known behavior of persons who take some psychotropic medications, can lead to an imbalance of electrolytes that can be fatal. These individuals can consume up to 15 liters of water daily, causing their blood levels of sodium to fall dangerously. Such information can provide much help to the medical examiner, as it may be that the only way to establish the presence of polydipsia in the deceased is by the person's history.

Sodium is not the only electrolyte that can be implicated in sudden death. Potassium is another. In physically compromised individuals who may not have been eating for days preceding their death, or in individuals who are taking diuretics or have been physically ill with diarrhea or vomiting can have low potassium levels. These levels can be lowered to lethal levels when a person engages in a violent struggle. Too much potassium can also compromise the individual. Some antihypertensives medications and diet changes may result in elevated levels of potassium.

The forensic literature includes a significant number of references to the presence of a beer belly (fat deposits in the abdominal region) as a risk factor for sudden death. Antipsychotics or mood stabilizers can significantly increase weight as one of their side effects. Thus, investigators may want to look further at the reasons for a subject's weight gain, as these same medications may have other adverse effects that may include lethal cardiac rhythm disturbances.

Behavioral History: Friends, relatives, neighbors, and coworkers can speak to evidence of a history of unusual behavior. Particular attention should be paid and significance accorded to behaviors recent to the fatal event. Investigators should determine whether the subject's physical or mental condition has worsened. Had the subject been looking after himself or herself? Are there significant stressors that can be identified that might have served as triggers for the violent outburst? Is there evidence of changes in relationships, work status, residence, health—anything that could lead to significant stress

Substance Abuse: It is important to look for evidence of any substance abuse. Investigators should check for history, duration, frequency, to what level, and types (cocaine, amphetamine, alcohol, or over-the-counter stimulants). Some cardiac conditions, such as the presence of a lethal heart rhythm, may result from the presence of one drug (such as cocaine) or the withdrawal effect of another (such as alcohol). Delirium tremens, the condition resulting from alcohol withdrawal, manifests itself in confusion, agitation, and disorientation among other symptoms. In the absence of treatment, the mortality rate from this condition can be as high as 15 percent.

The Common Link: In each of these histories, investigators should look closely for evidence of stressors. Scholars have long suspected the role of psychosocial stressors as precipitants of violent behavior in predisposed individuals, and of their role in the exacerbation of mental illnesses. In The Biology of Violence, Debra Niehoff details how the presence of environmental stressors can lead to a physiological accommodation predisposing a person into violent actions. Her set-point conceptualization posits that in certain individuals the nervous system becomes overly stimulated with each stimulus it encounters, thus requiring less of that stimulus to achieve the same effect over time. Thus, in some individuals, seemingly innocuous incidents will be perceived eventually as severe stressors to which they will respond. Knowing that environmental stressors can precipitate vulnerable individuals to sudden violent outbursts, such episodes can be better understood.

In addition, when individuals ingest substances of abuse, it can lead to a re-regulation of their physiology. In fact, chronic use of some medications and drugs can lead to a physiological neurological restructuring that has only recently been documented. The significance of chronic and acute stressors becomes even more significant when viewed against these physiological changes.

In a personal communication with one of the authors of this article, Dr. Niehoff referred to the importance of bearing in mind a "vicious circle" of aggression. This cycle refers to the idea that when a person perceives a threat in the environment and reacts with a hyperaroused, aggressive response, the very response serves as an additional stressor which sensitizes and "kindles" the nervous system. This sensitization and kindling alters the set point. This alteration means that less of a stimulus will be needed for the individual to react aggressively the next time. Thus persons who react aggressively will react more aggressively in response to less of a perceived threat in an ongoing cycle that feeds off itself.

The Incident
With regard to the incident itself, the investigator should determine the duration of objectionable behavior prior to police contact. The details of the person's behavior leading up to police intervention should be noted. Investigators should document in detail what was said and done by the subject. A description of the hyperaroused state might include elements such as hyperventilating, hallucinating, shouting, running, pacing furiously, or the presence of an exaggerated startle response.

It is also important to describe the type and duration of resistance exhibited by the subject and describe the nature and duration of their resistance. An approximation in descriptive terms of the person's emotional state would be helpful. For example, descriptors might include terms such as anger, fear, rage, and so forth. What behaviors were correlated with these emotions? For example, an observation might include whether the subject attempted to strike the officers in apparent defensive posture or in an offensive manner. An offensive stance might correlate with a rage response, whereas a defensive posture might correspond to fear.

Other contextual information that should be gathered would involve a description of the effort required to bring the subject under control. How many officers did it take? Were the officers sweating and winded afterward? In addition to these questions, the investigator might describe the fitness level, age, size, and experience of the officers necessary to gain control of the situation.

Important to the investigation are a description of how the subject was transported, how he or she was restrained, and how vigorously he or she struggled against the restraint. The duration of the person's agitated state (including agitation prior to police response), coupled with intense struggle against restraint, might exacerbate a potentially lethal condition known as rhabdomyolysis. This condition involves a breakdown of the muscles and a potential leeching of toxic substances resulting from this breakdown into the bloodstream. Rhabdomyolysis has been associated with intense agitated states, physical effort, overheating, and certain medications and drugs of abuse.

The circumstances surrounding a subject's death include an observation that the individual seems to become calm. This state of calm may mimic a state of compliance, but it can be a very dangerous sign that has been misinterpreted as being the termination of the struggle. It is imperative that officers who are involved in struggles with victims be vigilant and document that the person is indeed breathing and that they have a pulse when they cease to struggle.

When the person is transported to the emergency department, it is important that the subject's temperature is recorded. Ideally, core body temperature should be obtained before, at the time of, and after the subject's death. Although it may be impossible to get the subject's temperature during the struggle, body temperature can be an important clue for the medical examiner in determining what physiological mechanisms may have been operational that led to the subject's agitated state and eventual demise. Any observation indicating body temperature should be recorded.

With respect to resuscitation efforts, recommendations from the United Kingdom include asking whether thyroid or cricoid pressure (pressure over the front of the windpipe) was used when trying to intubate the subject. Intubation efforts can result in injury and interference with oxygen supplies. Investigators should also record the number of times the attempt was made and the name of the person who undertook the attempts.

Environmental Factors
The primary focus in this portion of the investigation deals with the climatic conditions to which the subject was exposed. The influence of temperature on the outcome of these types of incidence, which usually occur during warmer months of the year, has been mentioned in the forensic literature. Investigators should note temperature trends during the week prior to the event. Because people with mental illnesses may wear every piece of clothing that they own, even on the hottest of summer days, the appropriateness of what the individual in question is wearing should be noted. Subjects who are unclothed at the time of police contact may have been overdressed earlier. During an intense and prolonged struggle on a hot day, their body temperature may rise dramatically.

Investigators should make note of temperatures and relative humidity readings in the geographical areas and note whether the subject may have been further compromised physically by residing in areas with defective or deactivated climate controls. Similarly, the climate data of the room where the deceased has been stored should also be noted.

If medical personnel made attempts to restrain the subject at the scene, their condition must be noted and should match that of the subject. For example, if paramedics are sweating heavily the subject should be perspiring as well. A large discrepancy in their respective conditions is noteworthy, as an inability to discharge body heat through sweating, for instance, could reflect side effects of medication the subject has taken. The dimensions of the room in question and the number of people present at the time of the incident should also be documented. There may be a relationship between these variables and the temperature of the room at the time. This data should also be collected for any locations in which the subject is placed, including hospital emergency rooms.

If the subject was restrained on the ground, consideration must be given to surface temperature. This reading must be taken as close to the time of the incident as possible. Documented evidence is always preferable to extrapolated evidence. If this data was not obtained, another option is to retain the services of a forensic climatologist. Accident reconstructionists and other should have a contact name for this type of expertise.

The factors involved in a sudden in-custody death are more complex than previously considered. These factors are often interrelated and may be overlooked by untrained first responders. Any data not recorded at the time of the incident is lost.

Elements of the causes and conditions of these types of deaths are present in medical, forensic, and psychiatric research. This article has presented a comprehensive picture of these circumstances and conditions that include the events that precede the in-custody death, and those that are intrinsically unique to the deceased.

Subsequent research may uncover new information that requires the alteration of this protocol. However, this protocol is based on the most current information available in the research arena having to do with injury and death proximal to restraint use. Thorough and detailed exploration of such an incident, through protocols based in the research, have the potential of saving taxpayers money that might otherwise be paid out through lawsuits that erroneously blame police personnel for the in-custody death. In addition, family members of subjects and police officers who were left to worry and wonder about the details of these deaths may have their questions answered. ♦

Opinions in this article are those of the authors and do not necessarily reflect the official position or policies of the Ontario Ministry of Community Safety and Correctional Services, the Ontario Police College, or the University of Medicine and Dentistry of New Jersey. The authors wish to acknowledge the assistance provided by the reviewers of this article, Dr. T. C. Chan, associate professor of clinical medicine in the Department of Emergency Medicine, University of California, San Diego, and Dr. Gregory Mosdossy, assistant professor in the Division of Emergency Medicine, University of Western Ontario, London, Ontario, Canada.

Armstrong, L. E., ed. Exertional Heat Illnesses. Champaign, Ill.: Human Kinetics, 2003.
Mohr, W. K., T. A. Pettit, and B. D. Mohr. "Adverse Effects Associated with the Use of Restraint." Canadian Journal of Psychiatry 48 (2003): 330–337.
Niehoff, D. The Biology of Violence: How Understanding the Brain, Behavior, and Environment Can Break the Vicious Circle of Aggression. New York: Free Press, 1999.
Nuland, S. B. How We Die: Reflections on Life's Final Chapter. New York: Knopf, 1994.
Police Complaints Authority. "Policing Acute Behavioural Disturbance." London, March 2002 (revised). Retrieved February 3, 2002, from
Sapolsky, R. M. Why Zebras Don't Get Ulcers. New York: Freeman, 1994.



From The Police Chief, vol. 71, no. 1, January 2004. Copyright held by the International Association of Chiefs of Police, 515 North Washington Street, Alexandria, VA 22314 USA.

The official publication of the International Association of Chiefs of Police.
The online version of the Police Chief Magazine is possible through a grant from the IACP Foundation. To learn more about the IACP Foundation, click here.

All contents Copyright © 2003 - International Association of Chiefs of Police. All Rights Reserved.
Copyright and Trademark Notice | Member and Non-Member Supplied Information | Links Policy

44 Canal Center Plaza, Suite 200, Alexandria, VA USA 22314 phone: 703.836.6767 or 1.800.THE IACP fax: 703.836.4543

Created by Matrix Group International, Inc.®