Deaths in custody: Physical restraint, excited delirium and medico-legal investigation - A systematic review.

BACKGROUND/

OBJECTIVES

Deaths in custody represent a critical intersection between health care, law enforcement and human rights. By depriving an individual of liberty, the State assumes an enhanced duty to protect life and ensure access to adequate medical care. Any death occurring in custodial settings must therefore be regarded as potentially suspicious until clarified through a prompt, independent and technically robust investigation.

METHODS

This systematic review synthesizes and critically examines scientific evidence on deaths in police and prison custody, with particular emphasis on physical restraint, pathophysiological mechanisms, and medico-legal investigation practices. A systematic search of PubMed and Scopus (2010-2025) was conducted in accordance with PRISMA 2009 guidelines.

RESULTS

The evidence indicates that deaths in custody are predominantly multifactorial, resulting from the interaction between physical restraint, intense physiological stress, intoxication with psychoactive substances and individual vulnerabilities such as obesity or underlying cardiac disease. The concept of "excited delirium" remains highly controversial, lacking validated diagnostic criteria or specific biomarkers and is frequently used as a diagnosis of exclusion in medico-legal contexts. Physical restraint, particularly prolonged prone positioning with thoracic or cervical compression, may precipitate metabolic acidosis and restraint-associated cardiac arrest, even in the absence of significant hypoxemia. Experimental studies in healthy volunteers fail to reproduce real-world custodial conditions and should not be used to negate associated risks.

CONCLUSIONS

Rigorous and independent medico-legal investigation, including complete autopsy, toxicological analysis and contextual reconstruction, is essential for accurate causal attribution and institutional accountability. These findings have direct implications for forensic practice, death certification and the prevention of avoidable deaths in custodial settings.