This case study report, part of the Death in Custody Reporting Act (DCRA) Study, uses qualitative evidence to understand deaths in custody and reduce the number of deaths in the future.
This report is part of the Death in Custody Reporting Act (DCRA) Study, which is designed to generate significant advances in the knowledge and understanding of deaths in custody and to develop recommendations that support efforts to prevent and reduce such deaths. Analyzing 89 interviews with practitioners holding a variety of positions, the authors identified key themes within each sector related to agencies’ ability to achieve their missions and objectives while keeping the populations they serve—and their staff—well. Given differences in the nature of each sector, some of the themes were unique to the context of the sector; however, there were a number of cross-cutting themes that emerged consistently. These include both challenges and facilitators in preventing or reducing deaths in custody. All DCRA Study activities were conducted across three sectors in which adult and juvenile deaths in custody occur: law enforcement, jails, and state prisons. Each sector presents distinct causes and manners of death as well as situational factors that demand different practices, policies, and solutions to reduce these deaths. This report describes results from the case study component of the DCRA Study. Understanding why deaths occur and identifying effective policies, practices, and programs that can help reduce them is a key charge of the DCRA Study and this corresponding report. As part of Phase 2 of the DCRA Study, the authors conducted case studies with three law enforcement agencies, three jails, and four state prison systems to hear directly from practitioners about the beneficial practices, programs, and policies they implement that can help prevent or reduce deaths in custody and about the challenges they face in achieving these goals.