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Sudden In-Custody Death

A number of factors can cause a subject to suddenly die in police custody. Recognizing and reacting to them may help you save lives.

August 01, 2005  |  by Dr. Jeffrey Ho

It's a 20-degree night in a major American city, freezing rain is spitting out of a black sky, and the wind chill factor is well below zero. Local police respond to a call for assistance from the manager of a fast-food restaurant. A young man is running around the restaurant's parking lot naked, screaming nonsensical gibberish at the top of his lungs, and scaring the customers.

Two officers approach the man, trying to talk him down and get him to obey their verbal commands. The man repeatedly ignores commands from the officers and a confrontation ensues. Eventually, he is wrestled to the ground, handcuffed, and hauled to a patrol car for transport.

On the way to a hospital, the man kicks, screams, and spits. He struggles against the handcuffs. Then suddenly, he's quiet. One officer looks back at the prisoner and says, “This guy doesn't look so good.”

EMS is called and minutes later the prisoner is under the care of an emergency room team. But despite numerous attempts to revive him, he dies.

Each year in the United States, hundreds of people die in police custody of no readily apparent reason and without any trauma. In some cases, officers used one or more intermediate weapons on the subject prior to arrest, in others they used no weapons but one or more officers went hands-on with the subject, and in many others, officers barely touched the subject.

Often these cases lead to blaring headlines that read something like, “Man Dies After Fight with Police.” Such reports play on reader prejudice that all cops are brutal, and that the police somehow directly caused the death.

But the truth is deemed a little less newsworthy and is certainly much less sensational. The reality is that many people who die in custody suffer from one or more medical conditions that contribute to their mortality. Others have high volumes of drugs in their bodies that cause adverse physical reactions. Both conditions are magnified when the subject is confronted, subdued, and restrained by law enforcement officers.

Much of the discussion over what is commonly called in-custody death attempts to assign a single, uniform cause. As a society, we want to blame somebody or something for every unexpected death. This is why, over the years, reporters and human rights advocates have pointed a finger at police hand-to-hand combat techniques, pepper spray, and now Taser weapons as a primary cause of unexplained prisoner deaths.

Lacking in this analysis is an honest, objective, factual discussion of the phenomenon based on surveillance and known medical data. A growing body of documented experiences, autopsy results, and data compiled by various sources supports the theory that many in-custody deaths are not the result of a single cause but a cascade of multiple factors that is often set in motion long before law enforcement ever gets involved.

In-custody death is nothing new. A search of the medical literature shows that various reports and studies have noted the occurrences of in-custody death or syndromes that closely mimic it in institutionalized patients dating back to the 1800s.

More recently, physicians and medical examiners have ascribed these tragedies to cocaine intoxication, restraint/positional asphyxia, and metabolic acidosis. Here is what we do know. Medical post-mortem examinations generally support several distinct factors contributing to many in-custody deaths. In no specific order, these include: cardiomyopathy, excited delirium, metabolic acidosis, stimulant abuse/overdose, and positional/restraint asphyxia. Keep in mind that any or all of these factors may affect a single subject before, during, and after an arrest.


Cardiomyopathy means that the person has a structural heart abnormality that predisposes him or her to sudden cardiac arrest. This condition is often not recognized in younger people until it is found at autopsy. Abnormal heart structure is often an inherited trait. However, there are many lifestyle factors that can put a person at risk for developing the condition. These include excessive alcohol or drug use.

Because cardiomyopathy is often a silent condition that can present problems during times of extreme exertion such as fleeing law enforcement or resisting arrest, it's a common factor in many in-custody death cases. The most likely symptoms are chest pain, shortness of breath, and/or the sensation of an abnormal heart beat. However, it's not uncommon for the person to die so suddenly that no symptoms are reported. Medical researchers are still not entirely clear on how or why cardiomyopathy occurs or why it causes sudden death in some people and not others.

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