Investigation into deaths and harm in custody

25 Mar 2014

This Ombudsman's report provides an overview of common issues within Victorian prisons, and how these can lead to deaths and harm in custody.

Executive summary

  • The State owes a duty of care to every person detained in custody to ensure their safety and wellbeing. For example, in the Victorian prison system the Secretary of the Department of Justice has a statutory duty to ensure the safe custody and welfare of prisoners and offenders in the Secretary’s custody.
  • There are a number of rights that are engaged under the Victorian Charter of Human Rights and Responsibilities Act 2006 when a person is detained in custody, including a person’s right to humane treatment and the right not to be arbitrarily deprived of life.
  • The Victorian community should have confidence in what happens behind the closed doors of custodial facilities – that detainees are managed in a fair and consistent manner; that they are treated with dignity and respect for their human rights; and that those responsible for caring for detainees are held accountable for their actions.
  • Many people in custody are vulnerable, often with complex social, legal and medical histories. Each year a number of people die in custody, while many more experience some form of harm, injury or illness.
  • For over 40 years, the welfare of people in custody has been a concern of the Victorian Ombudsman. In a number of my reports to Parliament I have identified concerns about the treatment of people in custody and made recommendations to address such concerns.
  • Given continuing overcrowding in Victorian prisons and police cells, coinciding with an increase in the number of prisoner deaths in 2012- 13, I decided that an own motion investigation into deaths in Victorian custodial facilities was warranted. My investigation focussed on Victorian prisons, police cells, the youth justice precincts and the secure psychiatric hospital4 for people with serious mental illness admitted under the Mental Health Act 1986.
Publication Details
Published year only: 
Subject Areas
Geographic Coverage