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National Deaths in Custody Program

Among the concerns expressed by the RCIADIC in 1991 was the scarcity of reliable statistics on Indigenous contact with the criminal justice system. The final report of the RCIADIC (1991) recommended an ongoing program be established to monitor Indigenous and non-Indigenous deaths in prison, police custody and juvenile detention to gauge the impact of the recommendations regarding the rates of death in custody.

The program was to perform the following functions:

  • maintain a statistical database relating to deaths in custody of Indigenous and non-Indigenous persons;
  • report annually to the Australian Government; and
  • negotiate with all custodial agencies with a view to formulating a nationally agreed standard form of statistical input and a standard definition of deaths in custody.

In response, the NDICP was established at the AIC in 1992 and since then, has provided comprehensive and authoritative data on all deaths that occur in custody and custody-related police operations. Although the NDICP began recording information in 1992, data on all custodial deaths between 1980 and 1992 were collected retrospectively, placing the NDICP in the unique position of holding detailed information on custodial deaths in Australia over the past 32 years.

The NDICP examines the circumstances of deaths in prison, police custody and juvenile detention across Australia in each year of reporting and also monitors long-term trends. The purpose of monitoring deaths in custody is to provide accurate, regular information that will contribute to policy and programs that aim to reduce deaths in custody and to increase public understanding of the issues.

The RCIADIC outlined the types of deaths that would require notification to the NDICP (Recommendation 41). They are:

  • a death, wherever occurring, of a person who is in prison custody, police custody or detention as a juvenile;
  • a death, wherever occurring, of a person whose death is caused or contributed to by traumatic injuries sustained, or by lack of proper care, while in such custody or detention;
  • a death, wherever occurring, of a person who dies, or is fatally injured, in the process of police or prison officers attempting to detain that person; and
  • a death, wherever occurring, of a person attempting to escape from prison, police custody or juvenile detention.

With regards to deaths in police custody-related operations, the NDICP only monitors deaths of persons who are in the physical custody of police officers, or who are alleged offenders who die in the process of officers attempting to take them into custody. This program does not include deaths of persons who are simply clients of police services or innocent bystanders who have died in the course of a police operation.

Compiling the National Deaths in Custody Program

The information held in the NDICP database is based on two main data sources:

  • NDICP data collection forms completed by all state and territory police services, correctional departments and juvenile justice agencies and sent to the AIC directly whenever a death occurs (including additional information such as offence records and police narratives); and
  • coronial records, such as transcripts of proceedings and findings, as well as toxicology and post-mortem reports.

NDICP data collection forms allow information to be recorded on approximately 65 variables relating to the circumstances and characteristics of each death. Australian state and territory police and correctional authorities provide completed data collection reports and all relevant information is then extracted and entered into the NDICP database.

Coronial data used in the NDICP data collection process (including coronial rulings and findings, and toxicology and pathology reports) are accessed through the National Coronial Information System (NCIS) for every jurisdiction. The NCIS was formerly managed by the Monash University National Centre for Coronial Information and is currently based at, and managed by, the Victorian Institute of Forensic Medicine. After submitting an ethics application to the Monash University National Centre for Coronial Information to obtain access to the NCIS for the NDICP, the AIC was granted access in July 2001 on a fee-for-service basis. The AIC has renewed its ethics application every three years since, with copies of all presentations and publications produced by the NDICP provided to the ethics committee.

Indigenous status

For the purpose of the NDICP, custodial authorities indicate whether the deceased is known to be of Indigenous background and this information is recorded in the database. Upon the handing down of coronial findings, the Indigenous status of each deceased person is cross-checked to ensure accuracy.

Reflecting an ongoing concern regarding the development of an accurate picture of Indigenous representation in the criminal justice system, corrective services agencies have made considerable efforts to reduce the number of people in their custody with unknown Indigenous status. For example, since 2004–05, the proportion of the prison population with unknown Indigenous status has declined from 2.2 percent to just 0.08 percent (ABS 2011b). For an indication of the number of persons in prison custody with unknown Indigenous status see Table E3 at Appendix E.


The definitions used to determine whether a case can be deemed a death in custody are derived from the recommendations of the RCIADIC. The definition of a death occurring in police custody is based on a 1994 resolution of the Australasian Police Ministers’ Council (APMC; see Appendix C). Prior to that, only deaths occurring in police institutional settings (Category 1a) were reported to the NDICP and included in the dataset. The resolution of the APMC allowed the definition to be expanded so that deaths occurring during police operations (Category 1b and Category 2) could be included and distinguished from those in institutional settings. Category 1a deaths have been included in the NDICP since 1980 and police operational deaths (Category 1b and Category 2) have been collected since 1990.

Category 1:
(a) deaths in institutional settings (eg police stations/lockups, police vehicles, etc.; or during transfer to or from such an institution; or in hospitals, etc. following transfer from an institution); and
(b) other deaths in police operations where officers were in close contact with the deceased. This would include most raids and shootings by police. It would not include most sieges where a perimeter was established around a premises but officers did not have such close contact with the person as to be able to significantly influence or control the person’s behaviour. (It is proposed that this category be called ‘deaths in custody’.)
Category 2:
Other deaths during custody-related police operations. This would cover situations where officers did not have such close contact with the person as to be able to significantly influence or control the person’s behaviour. It would include most sieges as described above and most cases where officers were attempting to detain a person, e.g. pursuits. (It is proposed that this category be called ‘deaths during custody-related police operations’.) (see Appendix C)

Calculating death rates

The rates of deaths in prison custody presented in this report are calculated as the number of deaths divided by the total prison population multiplied by 100 and are expressed as the rate of deaths per 100 prisoners.

The data for the denominator are drawn from three sources:

  • the number of prisoners at midnight on 30 June each year. The prisoner census data was first collected in 1981 and are published in Prisoners in Australia by the Australian Bureau of Statistics (ABS) cat. no. 4517.0. In this report, these data are labelled ABS-A (ABS-A 2011–1981);
  • the average daily prisoner population. This is calculated from daily counts of prisoners, which are summed and then divided by the number of days in that month to determine the average daily population. These data were first collected in 1998 and are published in Corrective Services, Australia by the ABS cat. no. 4512.0. In this report, these data are labelled ABS-B (ABS-B 2011–1998); and
  • the average daily number of prisoners, which is published in the Report on Government Services by the Steering Committee for the Review of Commonwealth/State Services (SCRCSP 2012–1997).

The review of the NDICP in 2011 identified that the average daily number of prisoners is the more appropriate denominator rather than a single annual snapshot of the number of prisoners on a particular day. The count of prisoners at 30 June is generally higher than the average daily number, which is caused by a lag in court processing time. During the holiday period from December to January each year, the court system closes down. When the court re-opens, there is a backlog of cases that have to be processed. This leads to a situation where more offenders are sent to prison in the first quarter of each year than at any other time. Given that the prisoner census is conducted at 30 June each year, it captures this new flow of prisoners into the system, but fails to account for all of the prisoners who leave custody throughout the rest of the year. By contrast, the average daily number of prisoners is calculated from regular counts of prisoner numbers throughout the year and therefore more closely reflects the flow of prisoners into and out of the prison system each year. It is for this reason that the average daily numbers are now used in the calculation of rates of death in prison custody.

  • The prisoner population data from the ABS prisoner census is used to calculate the rates from 1980 to 1991 because reliable daily average population counts are not available prior to 1992.
  • The populations used as the denominator to calculate the various rates of death are provided in Appendix E at the back of this report.
  • For historical reasons and to enable comparison with previous NDICP reports, a graph showing rates of death using the census count as the denominator has been included in Appendix D.

Rates of death in police custody are not presented in this report because there is no reliable data source for:

  • the number of people who are placed into police custody each year; and
  • the number of people who come into contact with police in custody-related operations.

Further, some variables have missing data where there is unknown information or the AIC is awaiting further detail and as a result, there are differences in the number of cases that contribute to the various analyses. Analyses have been conducted for the total number of cases for which the relevant information is available.

Report content

This report presents data on deaths in custody collated from all jurisdictions from 1 January 1980 to 30 June 2011 and reports on trends since 1980. The variables presented in this report are:

  • Indigenous status;
  • age at time of death;
  • sex;
  • custodial authority at time of death;
  • time of incident for motor vehicle pursuit and shooting deaths;
  • cause of death, including hanging points and materials used for deaths caused by hanging;
  • type of natural cause death for prison custody;
  • manner of death;
  • mental health status of the deceased;
  • toxicology results are presented in aggregate form for deaths in police custody and custody-related operations;
  • location of death;
  • most serious offence;
  • legal status in prison at time of death; and
  • reason why the deceased was in police custody at time of death.

Motor vehicle pursuit and shooting deaths are two types of deaths in custody that attract a great deal of media and public interest. In a separate section of this report, the demographics of persons involved in these types of incidents are examined, as are the circumstances surrounding these events.

Timing of reporting

The timing of the release of this report is dependent on many factors including the collection of data from all jurisdictions, and the validation and cross-checking of information with coronial records. The analyses presented in this report also rely on population data from external sources, much of which is not available until several months after the end of the financial year. In order to improve the timeliness of reporting data collected by this program, a number of internal efficiency gains were implemented in 2011 in conjunction with a more streamlined data collection and validation process going forward. It is anticipated that future NDICP monitoring reports will be released approximately six to eight months after the end of each financial year.

Last updated
3 November 2017