‘One dead’—Number correct!: Deaths in custody – Forensic policy and reform
Across the world, one of the most fundamental duties of every prison, penitentiary and correctional institution is the constant counting and reconciliation of inmates—morning, evening, and emergency roll-calls—to ensure that every person in custody is continuously accounted for. This practice reflects the core custodial logic of corrections: numbers must always balance because each count represents state control over human life. Yet, within this arithmetic of custody, the phrase “one dead, number correct” is sometimes recorded, signifying that an inmate has inadvertently died and the numerical integrity of the prison has been restored.
Behind prison walls, where freedom is suspended and state power is absolute, death carries a heavier meaning. The number may be correct, but a death in custody is not merely a biological event; it is a test of accountability, legality and the moral authority of the state. Deaths in custody occupy one of the most sensitive intersections of law, medicine and human rights. Empirical studies and human rights reports across regions, from Europe to Africa, reveal a gap between law and practice. Correctional forensics addresses custodial death and provides an integrated framework for reforms and policy.
Ghana, over the years, amid challenges, has provided an integrated forensic framework involving custodial death, as evidenced in the Coroners Act, 1960 (Act 18).
Death in Custody: International Standards – What Best Practice Requires
Deaths in custody are fundamentally different from deaths in the free community. Once an individual is detained, the state assumes total responsibility for their life, health, safety and dignity. Sociologist Erving Goffman described prisons as “total institutions”—environments where all aspects of life are controlled by a single authority. In custody, this control is often intensified by overcrowding, understaffing, poor healthcare and aging infrastructure.
Deaths in custody are often attributed to “natural causes” without probing the institutional conditions—delayed care, neglect, abuse or excessive force—that may have made such deaths preventable. In such settings, the absence of robust external oversight turns prisons into epistemic black boxes. The coroner’s system is one of the few legal mechanisms designed to pierce that opacity in most countries. When coronial processes fail, prisons risk becoming spaces where death occurs without explanation and suffering without witness.
A custodial death therefore raises an automatic presumption of state responsibility that must be rebutted through transparent, independent investigation. International human rights law is unequivocal on this point. The UN Human Rights Committee has consistently held that states bear heightened obligations where persons are deprived of liberty (ICCPR, Article 6).
The UN Minnesota Protocol (2016) on the investigation of potentially unlawful deaths sets the global gold standard. It mandates that deaths in custody must be investigated promptly, effectively, thoroughly, independently and transparently. Similarly, the UN Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) require immediate reporting, independent investigation and medical examination of every custodial death (Rules 6, 24–27, 71). The Istanbul Protocol mandates thorough, independent forensic investigations for deaths in custody—documenting injuries to uncover torture or ill-treatment, and safeguarding the chain of custody to prevent concealment. Also, the ICRC Guidelines for Investigating Death in Custody (2013) reiterate: “All deaths in custody must be investigated promptly by an independent and impartial body, regardless of whether the relatives of the deceased request it.”
The African Charter on Human and Peoples’ Rights and the jurisprudence of the African Commission reinforce these obligations, emphasizing that failure to investigate custodial deaths constitutes a violation of the right to life.
Prisons Leveraging Ghana’s Coroners Act, 1960 to Meet International Standards
Ghana’s Coroners Act—the Eighteenth Act of Parliament of the Republic of Ghana, assented to on December 15, 1960—is remarkably clear on custodial deaths, despite mounting calls for reform more than 65 years after its enactment. Within this legal framework, the Prisons Service stands out for its emphatic and demonstrable adherence to the law, leveraging the growing specialty of correctional forensics to ensure transparency, accountability and justice in deaths occurring behind bars.
Under the Coroners Act, 1960 (Act 18), Section 1 establishes that every District Magistrate is a coroner within their jurisdiction. Crucially, Section 2(2) mandates that:
“The person in charge of any prison, lock-up, lunatic asylum or public institution other than a hospital shall forthwith give notice to the coroner of the death from any cause whatsoever of any person detained therein.”
The law allows no discretion—no internal screening and no administrative silence. Every custodial death triggers immediate notification to the coroner, meticulous documentation and preservation of medico-legal evidence. This practice is strengthened by correctional forensics—a subspecialty that integrates clinical medicine, forensic pathology, scene reconstruction, custody health records and chain-of-custody principles within the unique environment of incarceration.
Even more explicit is Section 5(1)(c), which requires a coroner to hold an inquiry where a death occurs “while detained in a prison or lock-up.” Unlike deaths in the general population, custodial deaths cannot be waived merely because they appear natural.
Importantly, Section 5(2) clarifies that this inquiry cannot be dispensed with in cases of custodial death, recognizing the inherent power imbalance in detention. The Act affirms a core forensic truth: in detention, context matters as much as cause.
Compliance is not optional. Section 3 — Penalty for Failure to Comply with Section 2 warns that offenders may face fines or imprisonment for failing to report a custodial death. The intent is clear: custodial authorities must account for every life lost under their watch.
Operating within this demanding legal environment, the Prisons Service has demonstrated leadership—through prompt reporting, coronial collaboration, postmortem facilitation and accurate clinical forensic records—showing that even an older statutory framework can support international best practice.
The Coroners Act, 1960 undeniably shows its age. Calls for amendment have grown louder—citing the need to modernise procedures, reflect advances in forensic science and align with evolving human rights standards. Yet until reform is enacted, the existing law remains binding. Ghana’s experience proves that compliance is possible despite challenges.
Reform and Conclusion
Comprehensive reform is essential in mandating forensic autopsies, independent inquests, family access, and transparent reporting for all deaths in custody. Forensic education and practices must be fully integrated into correctional governance, ensuring accountability and preventing it from being treated as an afterthought.
A death in custody is never just “One dead, Number Correct.” It is a moment that tests the integrity of prisons, corrections, and penitentiaries, the credibility of the justice system, and the moral legitimacy of the state. Ultimately, a society’s commitment to justice is reflected in how it investigates deaths in custody, giving the deceased a voice and assuring the living that detention does not equate to invisibility.
By Dr Lawrence Kofi Acheampong, Prof. Francis Agyemang Yeboah and Dr Osei Owusu-Afriyie – Pathologist
The writers are forensic experts
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