Far-reaching reforms to the police, justice system and health service in England and Wales are needed to reduce the risk of people dying in custody, a long-delayed report has concluded.

The report, ordered by Theresa May in 2015 while she was home secretary, contains 110 recommendations for overhauling the way in which the police and health authorities deal with vulnerable people, and how the police complaints watchdog investigates such incidents when they occur.

It is understood special groups have been set up in Whitehall to deal with the fallout of the report, covering police, health, coroners and the Independent Police Complaints Commission (IPCC).

The report by Dame Elish Angiolini QC says police vehicles and cells should not be used to transport or hold those detained under mental health powers, unless in exceptional cases. It also says the detention in police cells of those believed to have mental health issues should be phased out completely.



Responding to another key recommendation, the home secretary, Amber Rudd, said the starting presumption would now be that the bereaved should have legal aid-funded representation at an inquest following a suspicious death or suicide in police custody or in prison.

Other reforms and findings include:



There should be an end to police officers conferring after custody incidents, but before they make their statements.



There is evidence of racial disproportionality in police restraint deaths.



Video cameras should be used in every police van used to transport a prisoner and on every frontline officer.

The police watchdog should robustly challenge discrimination where there is clear evidence.



Mental health training should be given of the same standard across all 44 forces in England and Wales for officers and recruits, plus refresher training.



The introduction of “drying-out centres” – seen as a potential alternative to police custody or accident and emergency departments for those under the influence of drink and/or drugs and who require specialist supervision – should be reconsidered.

Relatives of Sean Rigg, Thomas Orchard, Olaseni Lewis and James Herbert, who all died in custody, welcomed the report and urged the government to implement its findings.

The report states that every prosecution over a death in custody in the last 15 years has ended in an acquittal. “In fact, there has never been a successful prosecution for manslaughter in this context, despite unlawful killing verdicts in coroner’s inquests,” it says.

“This does not prove that the criminal justice system has failed to deliver justice, but it goes to the heart of why families so often feel let down by the system.”

In its response to the review, the IPCC also said that fewer than 25% of its investigative staff were former police officers.

The National Police Chiefs’ Council lead for custody, Chief Constable Nicholas Ephgrave, said he welcomed the review.

“Police officers across the country strive every day to protect the vulnerable and save life, often in difficult and complex situations,” he said. “Every death is a tragedy for the family and friends of the deceased and each death profoundly affects all those who were in any way involved with that individual during their time in custody.”



He said the police had already been looking at the risks involved in the custody process, but admitted more needed to be done. “We are determined to use this report to further improve and refine our practice.”

The police were working with the NHS, the College of Policing and the Home Office, he said.

“Our aim is to ensure officers are trained to use the right form of restraint in the circumstances based on an assessment of risk, we are able to identify vulnerabilities when someone is brought into custody, and, where appropriate, people are transferred to health services as quickly as possible.”

A video was launched on Monday as part of an internal police awareness campaign about the most critical points in the detention and custody process, aimed at preventing deaths in custody.

Andy Ward, custody lead at the Police Federation, which represents tens of thousands of officers, said the report made many valid recommendations “but stops short of detailing how they are to be achieved against a background of continued austerity and police officer numbers dropping by more than 21,000 since 2010”.