Guidance to support the decision-making process of when not to perform cardiopulmonary resuscitation in prisons and immigration removal centres

1. Introduction

1.1. This guidance addresses the issue of inappropriate resuscitation following a sudden death in a prison, immigration removal centre (IRC), or residential short-term holding facility in the absence of a signed do not attempt cardiopulmonary resuscitation (DNACPR) document. It is designed to support prison, detention, and healthcare staff in making a decision as to whether resuscitation would be futile and therefore compromise the dignity of the deceased individual.

1.2 This guidance has been taken from the European Resuscitation Council guidelines for resuscitation 2015 which support current national guidance from the British Medical Association, Royal College of Nursing, His Majesty’s Prison and Probation Service and the Home Office and decision making in the prison or IRC setting.

1.3. Full current guidance is available on the European Resuscitation Council website and on the Resuscitation Council UK website and includes a decision-making framework to enable health care professionals, and patients to make decisions before a resuscitation situation occurs. Full guidance relating to DNACPR can be found on the Resuscitation Council UK website.

1.4 The above guidance also places greater emphasis on the importance of effective communication and recording of CPR This is of particular significance in the prison and immigration removal centre setting where health care, prison and custody/ detention staff are responsible for the care of prisoners/detainees.

2. Initiating and continuing cardiopulmonary resuscitation (CPR)

2.1 Evidence from Prison and Probation Ombudsman investigation reports following deaths in custody/detention, reveal incidents where prison and healthcare staff have tried to resuscitate someone who is already dead, and has no chance of Resuscitating someone who is dead is inappropriate, very distressing for staff and undignified for the deceased. Additionally, in some cases resuscitation has not been attempted where it is possible that the person was not dead.

2.2 In most cases CPR is an unplanned event and will not have been discussed or planned in In these circumstances, CPR will be commenced immediately whilst more information is obtained to help with any further decision making. If any information arises which is relevant to advance decisions or treatment refusal, continuing with CPR is deemed inappropriate.

2.3 Resuscitation must be started on all patients who are found not breathing and/or pulseless unless certain conditions exist. The European Resuscitation Council guidelines for resuscitation 2015; Section 11: The ethics of resuscitation and end-of-life decisions states “Resuscitation is inappropriate and should not be provided when there is clear evidence that it will be futile”. The guidelines go on to provide clear exceptions where CPR would be futile and are listed in appendix A.

2.4 In the prison and immigration removal centre estate the primary judgment to be made is whether rigor mortis is present. The answer to this will inform the decision about commencing CPR. Rigor mortis is the stiffening of the body after death and normally appears within the body around two hours after the deceased has died. Once the contracting of all the body’s muscles has taken place this state of rigor – technically referred to as the rigid stage – normally lasts anything from 8 to 12 hours after which time the body is completely stiff; this fixed state lasts for up to another eighteen hours.

2.5 The European Resuscitation Council guidelines state that in such cases, a non-clinician might be making a diagnosis of death but is not verifying or certifying death. CPR that has no chance of success in terms of survival is pointless and may violate the right for dignity in death.

2.6 If resuscitation is not carried out, a full explanation of the circumstances and reasons must be given and documented appropriately.

2.7 Staff who are not able to recognise rigor mortis should start resuscitation until advised otherwise by a competent member of staff. When the decision not to resuscitate a prisoner or detainee has been made by a competent, qualified nurse or other healthcare professional, it is inappropriate for them to be overruled by a senior prison or immigration removal centre manager. Nursing staff should always exercise their own clinical judgment in their practice and are supported to do this through the Nursing and Midwifery Council Code of Practice.

3. Further Resources

4. Paper informed by 

Dorset Healthcare University NHS Foundation Trust (2015) Cardiopulmonary Resuscitation Policy, Reference Number IN-185.

Nottinghamshire Healthcare NHS Trust (2014) Resuscitation, Recognition of Physical Health Deterioration and Emergency Oxygen Use in Adult Patients, Policy 1.20.

5. Appendix A

Definitions of the seven conditions that are plainly associated with death where resuscitation should not be attempted:


  • Mottling of the skin.
  • Small round patches; likeness to bruises.
  • Pallor of the skin.

The pooling of blood, which settles in direct response to gravity, because of absent blood flow. Often referred to as ‘mottling’ or the skin having a mottled appearance. Initially seen as small round patches mimicking bruises. Above the hypostatic engorgement (pooling of the blood) there is obvious pallor of the skin. The presence of hypostasis is a diagnosis of death – the appearance is not present in a live subject.

Rigor Mortis

  • Stiffening of the body; limbs are stiff (rigid) and difficult to move or manipulate; usually affecting smaller muscles first such as those in the face, neck, arms, and shoulders. Inserting an intubation tube would be difficult or impossible.
  • The body holds its position when moved.

Rigor Mortis is the stiffening of the body after death. Rigor normally appears within the body around 2 hours after the deceased has died. Once the contracting of all the body’s muscles has taken place this state of rigor – technically referred to as the rigid stage – normally lasts anything from 8 to 12 hours after which time the body is completely stiff; this fixed state lasts for up to another 18 hours.


Self-evidently incompatible with life. 

Massive cranial and cerebral destruction

Where injuries to the skull and brain are considered by an attending healthcare professional to be incompatible with life, such as catastrophic head injury.


The presence of full thickness burns with charring of greater than 95% of the body surface.

Traumatic hemicorporectomy

The body is completely cut across below the shoulders and above the hips through all major organs and vessels. The spinal column may or may not be severed.


Where tissue damage indicates the patient has been dead for some hours, days or longer.

These definitions have been based on Recognition of Life Extinct by Ambulance Clinicians.

Publication reference: PRN00828