A long-awaited unpublished official report into deaths in police custody says families who have lost loved ones have been failed by the system and recommends far-reaching reforms to the police, justice system and health service, the Guardian has learned.

The report, ordered by Theresa May in 2015 while she was home secretary, is yet to be published, prompting warnings from some groups that the government delay risks damaging public confidence.

The report by Dame Elish Angiolini QC will say there should be a ban on those detained under mental health powers being held in police cells, and being transported in police vehicles, except in exceptional cases. It will also say that holding those believed to be suffering from mental health issues in police cells should be phased out completely.

It says: “Guidance should not advocate the use of police custody on the grounds that the detainees behaviour would be difficult to manage in a health care setting.”

The report also says families of those who have died in police custody should receive “free, non means-tested” legal advice from the start of the process, through to an inquest.

This redresses the balance whereby police and state organisations are publicly funded, while families struggle to get legal aid and say the process is demeaning.

The report of nearly 300 pages makes more than 100 recommendations and would be a landmark in police community relations if they are implemented. The report’s reforms and findings include:

• Demanding an end to police officers conferring after incidents, before they make their statements.

• Saying “there is evidence” of racial disproportionality in police restraint deaths.

• Calling for video cameras in every police van used to transport a prisoner and on every frontline officer.



• Documenting controversial cases where police were dogged by allegations of excessive force.

• Condemning “victim blaming” via leaks to the media after a death that is said is seen as “deflecting blame” from police actions.

• Saying police must must be held to account at “an individual and corporate level” if restraint of a suspect is excessive, unnecessary or disproportionate.

• Calling on the police watchdog to robustly challenge discrimination, where there is clear evidence and “where it can be inferred”, the latter potentially giving wider latitude to find racial bias.



• Urging mental health training of the same standard across all 44 forces in England and Wales for officers, new recruits, plus refresher training. This is so officers are better placed to spot when people have mental health challenges.

In Whitehall, special groups have been set up to deal with the fallout, covering police, health, coroners and the IPCC.



The report calls for a national coroners’ service to iron out inconsistencies in how cases are handled and says the IPCC must do better in its work to gain public confidence. It also calls for the police watchdog to set up a deaths and serious injuries unit.

May wanted the review and report to herald reform to boost confidence in the criminal justice system, especially the police. She ordered the inquiry after meeting the families of Sean Rigg and Olaseni Lewis, who died after being restrained by officers in 2008 and 2010 respectively.

The group Inquest, which helps those whose loved ones have died after contact with the state, says 1,061 people have died in police custody since 1990, with no officers convicted in a criminal court

Critics claim that is due to a lack of accountability, but prosecutions have been brought, for instance in the case of Thomas Orchard,but juries in a criminal case have declined to convict, even if a different jury in an inquest has found the killing to be unlawful.

The numbers of deaths in police custody are broadly declining, from 65 in 1998 to 17 last year and 14 the previous year.

May hoped the review by Angiolini, a former chief lawyer to the Scottish government, would end “evasiveness and obstruction” suffered by families and “transform the relationship between the public and the police and to preserve the historic principle that the public are the police and the police are the public”.

In the Rigg case, it took an inquest to expose flaws in the IPCC investigation, but the family was told it needed to contribute £21,000 to get funding for a lawyer from legal aid. Rigg, 40, died in Brixton police station, south London, in 2008.

The IPCC had initially cleared police after an investigation now admitted to be flawed, but an inquest jury found police actions contributed to Rigg’s death and officers failed to uphold the detained man’s basic rights.

In the Lewis case, an inquest found he was killed by prolonged restraint on a mental health ward involving up to 11 police officers and the inquest jury concluded that excessive force contributed to his death.

The review calls for radical reform of restraint by police, including officers being instructed that prolonged use of restraint should lead them to them getting medical checks for suspects.

The report will also say: “There is evidence of disproportionate deaths of black and minority ethnic people in restraint-related deaths.” It adds such deaths triggers disquiet in communities and damages trust, which is “exacerbated” by a sense those responsible are not held to account.

May is known to have been concerned about the lower levels of confidence black Britons have in the criminal justice system compared with white Britons, and also believed it was not sustainable.

The Angiolini report condemns “victim blaming” via leaks to certain media after deaths that lead to “false narratives” about cases. Such instances damage the trust of families and communities is the system’s ability to try to deliver justice, the report says.

It raises concerns about police conferring with their colleagues after deaths in custody, before they give their account and says it should not take place before an initial account or statements has been given. The only exception is if there is an operational need.

The report says conferring fosters mistrust but this is not the first report to say that, and police have previously argued against any ban.

Police officers see a ban on conferring as unfairly treating them as suspects, not witnesses. Any ban on conferring would present a dilemma for the government, with the possibility of threats by armed officers to put down their weapons at a time when more are needed to counter the threat of terrorist attack.

The report also tells the IPCC to formally request in writing the suspension or placing on restricted duties of officers under investigation for criminal matters or for gross misconduct under the police discipline system, and if guilty of the latter, a presumption they will be dismissed.

Some in policing fear the report is overly critical of the police and does not adequately appreciate the challenges faced by officers. Some in the health service are concerned that mandating that mentally ill people always get a medical place is simply not possible in the current system without more resources.

There has been long-running tension between police and health chiefs about who should tend to society’s most vulnerable in an emergency situation. The ban on the mentally ill being held in police cells, instead of a medical setting, is something the police want.

The report was originally due to be completed last summer. The Home Office has not given a date for its release.

A Home Office spokesperson would say only that it would be published in “due course” and offered no explanation for why it remains unpublished.

On Friday, a separate report into racial disparities across the criminal justice system conducted by the Labour MP David Lammy is due to be published and also expected to contain critical findings.