Farhat Hussain Mirza  ( Department of Forensic Medicine, Dow Medical College, DUHS, Karachi. )
Akhtar Amin Memon  ( MBBS Student, Dow Medical College, DUHS, Karachi. )
Syeda Ezz-e-Rukhshan Adil  ( MBBS Student, Dow Medical College, DUHS, Karachi. )
Hamid Ali Paryar  ( Police Surgeon, Karachi. )

Objective: To assess the causes and manner of custodial deaths in Karachi, and to determine the factor of negligence on the part of the custodians behind such deaths.
Methods: The cross-sectional study involved the deaths in custody undergoing autopsy at Civil Hospital, Karachi, from January 2005 to December 2010. Autopsy was followed by histological examination, X-ray or CT scan wherever required. A proforma was also filled as per the standard autopsy protocol.
Results: There were 61 custodial deaths in Karachi during the six-year study period which met the inclusion criterion. There were 58 (95.1%) males and 3 (9.4%) females. Natural causes accounted for a majority of deaths (n=36; 59%), the most common disease being coronary artery disease (n=13; 21.3%). Unnatural causes accounted for 25 (41%) deaths, comprising 13 (21.3%) homicidal, 7 (11.5%) suicidal and 5 (8.2%) accidental. Deaths were more frequent in the age group ranging from 30-39 years (34.4%), while the overall age-range was from 19 to 75 years.
Discussion: Measures need to be taken to provide a wholesome environment for the prisoners. Code of conduct for the prisoners should be followed and judicial procedures shall be conducted at a quick pace. Torture should be avoided under all circumstances, and proper vigilance shall be kept to prompt suicidal deaths.
Keyword: Autopsy, Custodial deaths, Prisoners, Torture. (JPMA 62: 752; 2012).

Custodial deaths invite public wrath, concern and mass resentment in any civilised society because such an event indicates the lack of careful handling on the part of the authorities concerned. Custodial deaths mean deaths occurring in custody of law-enforcing agencies during processing, apprehension, detention, in lockup or jails, during interrogation or willful negligence of the investigating agency as well as convicts dying in hospitals.¹
Death in custody is becoming the most controversial episode that is condemned by every section of society. Even the state is required to protect the rights of the prisoners until proven guilty by a court of law.²
In spite of all the legal restrictions, deaths do occur in custody and require investigation as to whether the death occurred due to any disease process, or was a deliberate attempt to kill, or because of the use of brutal force. It is also documented in electronic and print media that the prisoners themselves resort to self harm/suicide by using some noxious material or other means to avoid third-degree torture perpetuated by the custodians.
This state of affairs require elaborate investigation on a scientific basis to satisfy the courts, the state, the relatives of the deceased and the public at large that no extra-judicial means were responsible for the death under question.
Statistical data collected from the record of 145,425 autopsies conducted between 1993 and 2004 in the USA reported only 202 cases identified and reviewed as custodial deaths (0.139%; 03 cases per year).³ In India, it has been reported by scanning the record of autopsies extending over 5 years (from 2000 to 2004) that there were 70 identified cases of custodial deaths (14 cases per year).⁴ Both were retrospective studies dependant on available records and not physical verification of causes/manner of the deaths. Official record of the Police Surgeon, Karachi, shows that during the year 2006, out of 1864 autopsies conducted at various centres in Karachi, only 10 were custodial deaths, whereas in 2009, out of 2090 autopsies, there were 11 such autopsies in Karachi.
In Pakistan, some non-governmental organizations, such as the Human Rights Commission, has worked on custodial deaths in relation to the violation of human rights,⁵ while in Australia, England, Srilanka, India⁶ and other developing countries, work has been done on custodial deaths in relation to torture.⁷ The present study is the first of its type in Pakistan to focus attention on the scientific aspects of custodial deaths and to highlight various causes of custodial deaths by performing meticulous autopsy which is an integral part of the investigation needed to dispel or sometimes confirm allegations that an act of commission or omission on the part of the custodians had led to, or contributed to, the death.⁸ It has been noted that individuals who die during physical restraint usually do so from a combination of factors, which often include drug toxicity in which illicit drugs are quickly swallowed to avoid detection ("body stuffers").⁹

The cross-sectional study extended over a period of 6 years, from January 2005 to December 31, 2010, and included all reported custodial deaths autopsied in Karachi. All autopsies were carried out at Civil Hospital, Karachi.
Only custodial deaths investigated by a magistrate as per the legal provisions under the Criminal Procedure Code Section 176 were included in the study. All other medico-legal cases autopsied as per the requirements of the law were excluded.
A full-scale autopsy was conducted in each case to ascertain the cause and manner of the death. In cases where no cause of death was concluded on gross examination, representative tissues were sent for histopathology to the Department of Pathology, Dow Medical College, Dow University of Health Sciences, while in cases of suspected poisoning, tissues/viscera were sent for toxicological analysis to the laboratory of Chemical Examiner, Government of Sindh, in Karachi. Conventional X-rays and CT scans were also conducted whenever required for the ascertainment of the cause of death at the Department of Radiology, Civil Hospital, Karachi. A proforma was filled up for each autopsy, as per the standard autopsy protocol.
Statistical data was analysed using SPSS version 16. Frequency and percentages were calculated for all categorical variables, including gender, cause and manner of medico-legal deaths along with the causative agent. For mean age, Standard Deviation was calculated.

A total of 61 inmates died in prisons of Karachi during the study period, including 58 (95.1%) males and 3 (4.9%) females. All the three females died at the Special Prison for Women and due to natural causes (one each due to hepatic encephalopathy, pulmonary tuberculosis and gastroenteritis at 40, 65 and 30 years of age respectively).
Among male deaths, the youngest was 19-year-old, while the oldest was 75. The corresponding ages among the females were 30 and 65.
The overall age range, as such, was from 19 to 75 years and the mean age at death was from 38.87 ± 14.685 years. The age group in which the maximum number of deaths occurred was from 30 to 39 years (n=21l 34.4%) (Table-1),

while only 1 (1.6%) death was reported among those aged over 70. Overall, 34 (55.7%) of the deaths were of people who were 35 years old or less.
Most of the custodial deaths were due to natural causes (n= 36, 59%), while 13 (21.3%) were homicidal, 7 (11.5%) were suicidal and 5 (8.2%) were accidental (8.2%) in nature (Table-2).


Out of the natural deaths, 13 were suffering from Coronary Artery Disease. Two were diagnosed with hepatic encephalopathy, while 3 were reported with high-grade viral fever. Besides, 2 inmates were positive with Human Immunodeficiency Virus (HIV). On external examination during autopsy, 15 (24.6%) showed manifestations of skin disease.
Of the violent deaths, homicidal (n=13, 21.3%) emerged as the leading cause (Table-3).

Of them, 4 died of acute lethal injuries to head sustained as a consequence of being hit by hard and blunt objects, and 4 by firearm injury.
In deaths by suicides (n=7; 11.4%), asphyxia due to hanging (n=5) emerged as the most common cause by means of constriction of neck using bed-sheets (n=2), waist-band of shalwar (n=2) and rope (n=1).
In accidental deaths (n=5; 8.19%), asphyxia due to poisoning in body-packers were the most commonly reported (n=3) while one case each was reported for burn injury and electrocution.
The mean incidence of custodial deaths brought for autopsy was found to be 10.16 per year with the highest incidence (n=12, 19.7%) reported in 2008.

This is the first autopsy-based study auditing the custodial deaths in Karachi regarding the frequency of cause, manner, age and gender. Causes and mannerism of custodial deaths undoubtedly reflect the standard of treatment and facilities provided to the prisoners. This also reflects on the sense of responsibility and concerns of the security departments towards the inmates.
The study indicated natural causes to be the reason of death in more than half (59%) of prisoners. This slight deflection towards natural causes clearly shows that the conditions of housing and living standards are improving for the inmates in Karachi. Previously, a study from Pakistan had reported that a total of 91 prisoners died in custody during 1992.¹⁰ No other study to our knowledge has been reported from Pakistan on the matter.
Studies in India show a similar trend as Bansal et al reported that 89% of the prisoner deaths in Chandigarh were due to natural cause.¹¹ Bardale et al reported 82.85% deaths to be of natural cause in Nagpur, India.^[4] Recently, Vaibhav S reported very high percentage (95.45%) of natural deaths in eastern Maharashtra.¹²
Studies from North America indicate majority of prisoners dying of violent causes. A study from Canada during 1990-1999, reported 59% of deaths in custody caused by violence,¹³ while Okoye et al report 55% of prisoner deaths as violent in Nebraska, USA.¹⁴
Another important finding of our study related to the fact that the majority (88%) of prisoners who died due to violent causes, were below 40. Besides, all the suicides were found in the 20-39 age group. This indicates higher susceptibility of young inmates to mental disturbances, leading to death, which was also noticed and reported by other studies.¹⁵
Within the natural deaths, ischaemic heart disease stood out as the major culprit, causing 13 (36%) deaths, followed by hepatic failure and hyperpyrexia, each causing 3 (8.3%) natural deaths. This high rate of natural deaths brings into focus unhygienic sanitation facilities as the prime cause which, again, has also been reported by other studies.^16,17 Also found to be prevalent were transmissible diseases like HIV and hepatitis which could have been preempted by avoiding overcrowding as stated by the Rule 760 of the Prisons Act. The presence of skin diseases was also due to the same reason.
A survey of various prisons in Karachi revealed massive overcrowding. For instance, the Central Jail has the capacity to house 2500 prisoners, while currently it houses 5000-6000 inmates. Similarly, Malir Jail has a capacity of 650 inmates, while currently it houses about 3000 prisoners. Also, the survey reported that the budget for medicine is very meagre which is insufficient to treat even common illnesses, and the food supplied is sub-standard. Overall, it results in violent reaction from the prisoners in the form of strikes and damage to the prison\\\'s property.
Illegal drug trafficking in the form of body-packers was also found to be common and resulted in 3 custodial deaths during the study period. This can be avoided leading to decrement in the ratio of accidental deaths by drug poisoning as well as addiction among prisoners.
Unhygienic food provided to the inmates manifested a lack of concern on the part of the authorities. Strict measures are required, including providing a clean and better environment in prisons, better quality food and regular checkups by healthcare providers in order to prevent the rate of death. According to the WHO guidelines, prison staff should be educated to address the basic Health issues.¹⁸ UN also provides certain Standard Minimum Rules for the Treatment of Prisoners.¹⁸ These rules are required to be followed as was also recommended by the World Congress on Men\\\'s Health which considered poor sanitation in prison to have a "major impact" on their health.¹⁹
Homicides claimed 13 (21%) lives, which is higher than 11.8% reported in Nebraska, USA,14 and requires preventive measures by the authorities.
Torture can be administered through physical, psychological, pharmacological and sexual assaults.²⁰ Methods of physical torture include falanga, passing the board, suspension, hair torture, burns, dry submarine, wet submarino, telefona, forcing the person in abnormal position, forcing bamboo sticks under the fingernails, electric baton shock, irritant torture, cold torture, forced feeding and non-fatal shooting. Psychological torture includes deprivation technique, coercion technique, communication technique and witness torture. Pharmacological torture includes forced ingestion of psychotropic drugs or products like broken glass, that cause internal damage and pain. Sexual torture includes rape, fellatio, forced masturbation, forced abortion, forced nakedness and sexual humiliation.²⁰
Our study found that physical trauma with hard and blunt objects was the most common cause of homicidal deaths in custody (n=7) followed by firearm (n=4). Physical torture shall never be allowed under any circumstances as also advised by the WHO.²¹ Rule 731 of the Prisons Act states that precautions should be undertaken by the superintendent to assure the prevention of accidental and suicidal deaths. Several deaths have been reported till now at the Guantanamo Detention Centre.²² Reports have confirmed brutal treatment of the prisoners; that has led to suicides by the mentally disturbed prisoners.²²
The study found 11.4% (n=7) suicidal deaths which were less than the 20% which was reported in Greece.²³ But all of the suicides reported were in young males in the 20-39 age group, as also found in Ohio by Davis et al.²⁴ Our mean age of custodial deaths was 23 years, which is quite low as compared to 45.6 years in Nagpur.⁴ This shows that strict actions are yet required to corroborate the decrement of death rate in the young inmates. Young prisoners need to be dealt with very cautiously as torturing them will lead to mental disturbances which may manifest itself in the form of suicides. Proper counselling and less torture can help the department in controlling the inmates. The International Covenant on Economic, Social and Cultural Rights (ICESC) recognises the right of everyone to the enjoyment of the highest attainable standard of physical and mental health²⁵ and it should be implemented by the various agencies concerned.

Improving prison conditions and expediting the judicial process to facilitate the release of under-trial prisoners, if innocent, is necessary to decrease exposure to the harsh environment of prisons. Such steps would help to convert the prison into correction facilities and may help the inmates to become more functional and responsible citizens in the future. Further studies are needed in this regard that can stress on the significance of correction facilities and their impact on the mental and physical development of the inmates.

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