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J Indian Acad Forensic Med. October- December 2011, Vol. 33, No. 4 ISSN 0971-0973 The findings are in agreement with Fazel et al however, Wobeser et al and Frueshwald et al had noted majority of deaths by cardiovascular diseases in young people. [2, 3] As far as tuberculosis is considered, about 25.35% inmates were suffering from the infection and amongst them 11.97% had disseminated tuberculosis while 14.08% were associated with HIV infection. About 4.22% inmates were defaulter. Previous reports also highlight the high prevalence of tuberculosis in prisoners. [4-6] Prisoners constitute a high risk group for acquisition of tubercular infection as compared to general population owing to overcrowding, closed living conditions, insufficient ventilation, poor living conditions and poor nutrition. [13] There is urgent need to identify such individuals and initiate treatment. Nevertheless, the public health authorities should initiate a special action plan for these inmates. The associated conditions affecting the prisoners and it were noted that 16.90% had systemic hypertension, 10.56% had cerebrovascular episode, 10.56% had anemia, and 7.04% had chronic renal failure and so on. (Table 7) Therefore identifying such individuals and providing appropriate treatment would prolong the life of inmate. Conclusion and Suggestions: Custodial deaths are among the most difficult and contentious deaths for investigation. The inmates in custody are marginalized populations that have poor access to healthcare in the community. The Magistrate inquest is conducted for all deaths in custody and is the only means of inquiry available to obtain information. Unfortunately, the inquiry reels around the cause of death and nothing substantial surfaces out regarding preventive aspect. The Article 21 of the Constitution of India enshrines the fact that no person shall be deprived of his life and personal liberty except according to the procedure established by the law. Though it is true that not every case of death in custody will be avoidable but it is possible to reduce the number of such deaths by preventive measures. [14] An attempt had been made in this study to identify the mortality pattern in custodial setting and some measures are suggested as below: Reception Screening: The prison authorities should have detailed history of the inmate along with treatment record, follow-up record, investigations, any operative measures taken etc. History regarding alcohol dependence/drug abuse should be recorded. Any history of psychiatric illness needs attention. A specific 330 form may be designed for this purpose and should be filled at the time of reception. If needed, initial medical evaluation should be undertaken. Medical Facilities: Improper medical facilities and inability to provide timely medical aid are the major areas and the prison administration needs to work on this aspect. A structured delivery of health care services can be provided by setting ―Prison Health Services‖. The coordination with academic institutes should be encouraged and for this purpose the help of telemedicine could be taken to access to subspecialties and superspecialties. The management of illness could be improved by using standard disease management guidelines. The medical record should be computerized. The Doctors working in these institutes should be encouraged to undergo periodic continued medical education program. This will lead to improved medical care for prisoners and this not only would be a humane course of action, but also would serve the best interests of society as a whole. [15] Improving the Prison Condition: The prison conditions need improvement relating to the design and structure. Decongestion of the cells is needed. The dietary plan for the inmate as per illness (for e.g. chronic renal failure, diabetes mellitus) should be considered. If needed, the help of dietician should be taken in consultation with the treating physician. Research: Commissioning research and interdisciplinary help is the need of the hour. Feedback from the referral institutes and monitoring of the existing health care facilities should be undertaken. Training of Custodian People: The people related with custodial responsibilities should be properly trained for providing primary aid and to recognize when medical intervention is required. Similarly these people should be sensitized to treat the inmates with compassion. Awareness of prisoners: this is important aspect because without the initiative and willingness of these people any action taken by the administration would be ineffective. References: 1. Fazel S, Benning R. Natural deaths in male prisoners: A 20 year mortality study. Eur J Public Health 2006;16: 441-4. 2. Wobeser WL, Datema J, Bechard B, Ford P. Causes of death among people in custody in Ontario, 1990-1999. CMAJ 2002; 167: 1109-13. 3. Fruehwald S, Frottier P. Death behind bars. CMAJ 2002;167:1127-8
J Indian Acad Forensic Med. October- December 2011, Vol. 33, No. 4 ISSN 0971-0973 4. Bansal YS, Murali G, Singh D. Custodial deaths – an overview of the prevailing healthcare scenario. J Indian Acad Forensic Med 2010; 32: 315-7 5. Bardale R, Shrigiriwar M, Vyawahare MS, Dixit PG, Tayade SN. Death behind bars: A five-year study of custodial deaths. Medicolegal Update 2005;5:10-12 6. Sonar V. A retrospective study of prison deaths in western Maharashtra (2001-2008). Medicolegal Update 2010;10:112-4 7. Huddleston DJ, Kocoshis TA. Death in custody due to a colopericardial fistula. Am J Forensic Med Pathol 1997;18:194-8 8. Young JG, Chiasson DA, Cairns JT, Payne-James J, Carter EJ. Custody and restraint deaths. In: Payne- James J, Busuttil A, Smock W (eds) Forensic Medicine – clinical and pathological aspects, 1 st ed 2003. Greenwich Medical Media Ltd, London. 115-32 9. Copeland AR. Death in custody revisited. Am J Forensic Med Pathol 1984;5:121-4 10.Bhana BD. Custody related deaths in Durban, South Africa, 1998-2000. Am J Forensic Med Pathol 2003;24:202-7 11.Southall P, Grant J, Fowler D, Scott S. Police custody deaths in Maryland, USA: An examination of 45 cases. J Forensic Leg Med 2008;15:227-30 12.Smialek JE, Spitz WU. Death behind bars. JAMA 1978;240:2563-4 13.Stead WW. Undetected tuberculosis in prison. JAMA 1978;240:2544-7 14.Heide S, Kleiber M, Hanke S, Stiller D. Deaths in German police custody. Eur J Public Health 2009;19:597-601 15.Barclay WR. Medical care in prisons. JAMA 1978; 240: 2570. Table 1: Sex-wise distribution of cases Sex No. of cases (%) Range (in years) Mean age Male 138 (97.18) 21-78 46.63 Female 4 (2.81%) 40-70 52.5 Combined 142 21-78 46.80 Table 2: Age-wise distribution of cases Age group (in yrs) Male Female Total cases % 21-25 9 -- 9 6.33 26-30 9 -- 9 6.33 31-35 23 -- 23 16.19 36-40 17 2 19 13.38 41-45 15 -- 15 10.56 46-50 12 -- 12 8.45 51-55 16 -- 16 11.26 56-60 10 1 11 7.74 > 61 27 1 28 19.71 Table 3 showing type of custody Type of custody Number of cases % Jail 135 95.07 Police 7 4.92 Table 4: System-wise cause of death System affected No. of cases % Cardiovascular system 27 19.01 Central nervous system 17 11.97 Gastrointestinal system 12 8.45 Genitourinary system 10 7.04 Infectious diseases 08 5.63 Neoplasm 9 6.33 Respiratory system 58 40.84 Others 1 0.70 Table 6: Tuberculosis related deaths Tuberculosis Number of cases % Pulmonary tuberculosis 19 13.38 Disseminated tuberculosis 17 11.97 Associated with HIV 20 14.08 331 Table 5: Cause of death Cause of death No. of cases % Adenocarcinoma ovary 2 1.40 Adenocarcinoma intestine 1 0.70 Bronchial asthma 2 1.40 Carcinoma larynx 2 1.40 Cerebral infarction 2 1.40 Carcinoma gall bladder 1 0.70 Carcinoma lung 1 0.70 Carcinoma oesophagus 1 0.70 Cardiac tamponade 1 0.70 Cerebral abscess 1 0.70 Cerebral oedema 3 2.11 Consolidation 20 14.08 Encephalitis 2 1.40 Epilepsy 1 0.70 Gastric carcinoma 1 0.70 Gastroenteritis 2 1.40 Gastrointestinal hemorrhage 1 0.70 Hemolytic anemia 1 0.70 Hepatitis 2 1.40 Hepatic failure 3 2.11 Intestinal obstruction 1 0.70 Intracranial hemorrhage 7 4.92 Ischemic heart disease 24 16.90 Meningitis 1 0.70 Myocarditis 2 1.40 Pancreatitis 3 2.11 Renal failure 10 7.04 Septicemia 8 5.63 Tuberculosis 36 25.35 Table 7: Presence of associated illness Associated conditions No.of cases % Anemia 15 10.56 Alcohol dependence 7 4.92 Alcohol liver disease 10 7.04 Bronchial asthma 2 1.40 Cerebrovascular episode/paraplegia 15 10.56 Chronic obstructive pulmonary disease 6 4.22 Chronic renal disease 10 7.04 Chronic Suppurative Otitis Media 2 1.40 Cocaine abuse 1 0.70 Dementia 3 2.11 Diabetes mellitus 3 2.11 Generalized cerebral atrophy 2 1.40 Hepatitis 3 2.11 Human immunodeficiency virus disease 20 14.08 Hypoprotenemia 7 4.92 Ischemic heart disease 8 5.63 Lepromatous leprosy 1 0.70 Parkinsonism 1 0.70 Psychiatric illness 6 4.22 Pyelonephritis 2 1.40 Rheumatoid arthritis 1 0.70 Seizure disorder 8 5.63 Sickle cell disease 2 1.40 Systemic hypertension 24 16.90 Tuberculosis (defaulter) 6 4.22 Fig1: year-wise distribution of the cases 30 20 10 0
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