IPOC's annual report on deaths during or following police contact for 2024/25

The annual report on deaths in custody from the Independent Office of Police Conduct helps us to assess progress in health and criminal justice, specifically in regard to police custody.

The long term trend is that deaths in custody have remained constant over the last 15 years. There was a substantial improvement between 2004-05, when there were 36 deaths, and 2008-09, when there were 15 deaths. The average number of deaths per year has been 18 since then.

This year’s figure, of 17 deaths, is in line with that medium term trend. As the director of the IOPC said, “Behind every death is a human story - each one is a terrible loss for their family and friends.”

As in previous years, health is a key factor. Rachel Watson, IOPC director, said: “It is disappointing that mental ill health remains a common factor in so many of these deaths.” Of the 17 deaths in 2024-25, the report found:

• “Nine people had mental health concerns. The types of mental health concerns included depression, anxiety, bipolar disorder and self-harm.”

• “Fifteen people were known to have a link to alcohol and/or drugs. This meant that at the time of their arrest they had recently consumed, were intoxicated by, in possession of, or had known issues with alcohol and/or drugs. Where cause of death was reported, a pathologist recorded that alcohol or drug toxicity, or long-term abuse, was likely to be a contributing factor in the deaths of four people.”

As the director of the IOPC emphasised, reducing deaths and serious harm in police custody is not just a task for the police service: “We know that policing cannot do this alone and a wider, multi-agency response is required.”

That joined-up response should include joined-up information across health and criminal justice, which is the SONAR mission. We want to ensure that no serious harm in police custody or other CJS setting takes place because practitioners did not have up-to-minute information on health conditions and needs. As I have previously written, the Government’s efforts to introduce a single patient record across the NHS can be an important step to building a shared care record in health and criminal justice.

John White

Founder & CEO

Health Services Safety Investigations Body (HSSIB) Report Reflections

SONAR’s mission to share health information across different agencies applies to the wider health system as much as to Criminal Justice. I was struck by a recent report by the Health Services Safety Investigations Body (HSSIB), an arm’s length body of the Department of Health and Social Care which investigates patient safety concerns across the NHS in England.

The report looked at primary care and specifically people with long-term conditions who can be in frequent contact with the healthcare system. As the Health Foundation has shown, the burden of disease is gradually shifting “towards conditions that are predominantly managed in primary or other non-acute care settings”, such as diabetes and mental health conditions such as anxiety and depression.

Ideally people with long-term conditions will find primary care easy to navigate and fully aware of their health information. As the HSSIB reports suggests, this is not yet in place universally:

“People who are unable to navigate the health and care system can experience deterioration of health, miss appointments or their care may become delayed or forgotten about, meaning they may need more intense treatment in the future or longer stays in hospital.”

“Patients and carers have to retell their health history to different health and care providers. They believe the system is not joined up and that information does not flow across health and care organisations, or that different parts of the system cannot access information from other providers.”

The consequence is real difficulty for patients and their carers:

“Patients and carers can feel exhausted, burnt out, frustrated, angry and guilty, among other emotions. Patients and carers physical and mental health may deteriorate because of the extra burden of navigating the health and care system.”

The HSSIB concludes by making a “safety recommendation”:

“HSSIB recommends that the Department of Health and Social Care works with NHS England and other stakeholders, to develop a strategy that ensures that all diseases are given parity and that all people with a long-term condition in primary, secondary, tertiary and community or social care have their care effectively co-ordinated across multiple agencies. This is to ensure that people with long-term health conditions have co-ordinated care plans with effective communication between services and a single point of contact for concerns or questions.”

The sharing of healthcare information is clearly at the heart of delivering this improved, safer service. The Government’s Data Use and Access Bill will help. As the Government’s description of the Bill says,

“The NHS does not lack data; rather, it faces challenges due to data being fragmented across multiple sources.”

The Bill aims to ensure that health and care data is recorded and managed in the same way, by making information standards mandatory for all suppliers of IT services.

Clearly our work at SONAR will help to deliver what the Government is trying to achieve. We will provide access to accurate and up-to-date healthcare data across criminal justice and into all NHS organisations. As the HSSIB report shows, the development of modern, connected healthcare will improve the lives of so many patients, carers and families.

SONAR will be our contribution to this important goal.

John White

Founder & CEO

Improved Outcomes

My best seasonal wishes to all our readers.

What motivates the SONAR team is the chance to improve outcomes for people in the criminal justice system through better healthcare. As such, I will praise three individuals and organisations for their work in 2025 so far.

The first is Dame Carol Black, who has carried out several independent reviews of drugs policy for successive governments. Her aim has rightly been to make sure that vulnerable people with substance misuse problems get the support they need to recover and turn their lives around, in the community and in prison.

Speaking in February, she set out in detail how a lack of joined-up healthcare information for prisoners hampers efforts to recover from drugs. To quote her important words in full:

“For a drug-dependent person leaving prison there are at least six individuals or bodies that participate in trying to get them safely from the secure estate into treatment in the community. How well it is done varies from prison to prison.…

“The treatment inside the prison, the treatment in the community and the community probation service are the three crucial things, but there are six groups involved. On the whole, their computer systems do not talk to each other. They are all very well-intentioned people, and they all want the prisoner to leave and to go to their treatment appointments.

“I am sure you are aware that the number of deaths of drug-dependent people in the three-week period after leaving prison has been on the increase.”

The second is the Independent Sentencing Review commissioned by the Ministry of Justice in London. Its interim report, also published in February, bravely challenged the idea that penal policy should be primarily driven by punishment:

“The reality is that our prison population has grown very rapidly over the last 30 years … It is an approach that has emphasised the importance of punishment understood primarily as incarceration – an important aspect of sentencing policy – but has been insufficiently focused on the most effective ways to reduce crime. The rise in the prison population, for example, has meant that resources have been diverted away from activities that could reduce reoffending.”

The third is the very similar independent Commission on sentencing, in this case set up by the Scottish Government. The Scottish Justice Secretary, Angela Constance, gave a strong message in favour of rehabilitation:

“Prison will always be necessary for those who pose the greatest risk of harm, and protecting victims and the public is my absolute priority. However, evidence shows that short prison sentences are often not the best way to reduce reoffending, with those released from short custodial sentences reconvicted nearly twice as often as those sentenced to a community payback order. While crime is at one of its lowest levels in 50 years, we all want to keep crime down and communities safe, and effective rehabilitation to reduce reoffending is a key part of that.”

SONAR CMS can help all of these initiatives through its Custody module, which collects all healthcare information for prisoners and for ex-offenders respectively. I would be delighted to discuss the features with all interested commissioners. I hope we can play an increasing role in the new criminal justice system, ever more focused on the wellbeing of users and citizens.

John White

Founder & CEO