How to Prevent Another Unexplained Youth Death: Discussing Best Practices for Custodial Death Investigations

Five years ago (2013), a juvenile surnamed Mai at the Taoyuan Juvenile Guidance Home died, and to this day, the complete truth is still considered unrevealed. He suffered from ADHD and emotional disorders, and had sustained varying degrees of sprains and contusions on multiple occasions. Two days prior to his death, because his physical condition was deemed disruptive to the class routine, he was placed in solitary confinement. He ultimately died of sepsis triggered by suppuration of the thoracic and abdominal organs. Some speculate that he was ostracized within the guidance home due to his physical and mental disabilities, and that he died from wound infections that worsened after being beaten. Others speculate that he may have been physically punished with one-armed push-ups for disobeying rules, and that injuries sustained during this exercise led to his death. Meanwhile, the official narrative from the Taoyuan Juvenile Guidance Home at the time was that no one bullied him or subjected him to physical punishment; rather, he was overly competitive, challenged someone to a contest of one-armed push-ups, sustained injuries in the process, and picked at his wounds, leading to worsening infection and death.

Some personnel at the guidance home believe that the death of the juvenile surnamed Mai happened five years ago, has nothing to do with the current guidance home, and does not need to be brought up again, as doing so only damages the social trust in the institution. However, several legislators, Control Yuan members, juvenile probation officers, attorneys, and family members concerned with children's rights still harbor doubts about this case, believing that the truth remains unclear and a grave injustice has been left unredressed.

Regardless of which view one holds, the following question must be faced: If a death incident occurs again in a juvenile correctional facility, will it be possible to avoid the circumstances where the truth was deemed unclear, as happened in the case of Mai's death?

Youth death incidents happening again in juvenile correctional institutions are not alarmist; just last year (2017), at the Changhua Juvenile Guidance Home, a juvenile surnamed Li died after being punched five times as a disciplinary lesson by a roommate surnamed Hung for failing to return a beverage to their cell. Furthermore, some of the issues that emerged during Mai's death investigation recurred. If we pragmatically acknowledge that it is impossible for juvenile correctional institutions to experience zero deaths in the future, establishing a trustworthy death investigation mechanism is crucial.

The Control Yuan has issued investigative reports on both death incidents. In these reports, one can clearly sense the Control Yuan's distrust toward how the guidance homes handled the deaths, and it noted instances where it believed the guidance homes obstructed investigations and potentially concealed the truth. However, it did not consciously address how a trustworthy custodial death investigation mechanism should actually be established.

This article will use the investigations into the death of the juvenile surnamed Mai at the Taoyuan Juvenile Guidance Home (hereinafter referred to as the "Mai Case") and the beating death of the juvenile surnamed Li by Hung at the Changhua Juvenile Guidance Home (hereinafter referred to as the "Li Case")^[1] as examples to discuss how custodial death investigation mechanisms can be reformed.

How to Establish a Trustworthy Custodial Death Investigation Mechanism

To establish a trustworthy death investigation, the following recommended practices can be adopted. Taking the Mai Case and the Li Case as examples, the shortcomings are listed in the table below.

1. Gaps Between Correctional Institution Actions and Recommended Practices

   Item	Mai Case	Li Case	Recommended Practice
   Notifying Investigative Units	Only reported to the prosecutor for an autopsy examination, with no notification to the police to secure and gather evidence at the scene. The Control Yuan was also not notified.	Chaotic. First notified the prosecutor, later notified the police but prevented them from entering the facility to investigate immediately. Notified the juvenile court several days later. The Control Yuan was not notified.	Upon discovering a death, the correctional institution should immediately seal off the scene and notify investigative units.
   Preserving Evidence	CCTV footage was incompletely preserved.	Insufficient data.	The correctional institution should collect, preserve, and hand over to investigative units "all" items belonging to the deceased, as well as documents or records related to the deceased, including medical documents such as medical records.
   Cooperating with Investigations	Instructed subordinate personnel to specifically report back the content of their questioning before and after being investigated by the district prosecutors office, monitoring and standardizing their statements. Failed to provide all student interview records to the Control Yuan, and students showed suspected collusion in their statements.	Prevented the police from entering immediately and preemptively took statements from the juvenile.	The correctional institution should allow investigative units to thoroughly inspect the interior of the institution, obtain necessary documents or records, and inform everyone to cooperate with the investigation rather than preemptively taking statements and monitoring everyone's testimonies.
   Fact-Finding	Internal investigation concluded that relevant personnel had no negligence; several were subsequently impeached by the Control Yuan.	Internal investigation quickly concluded that only the administrator on patrol that day had negligence and issued a reprimand, but this was refuted by the Control Yuan.	Correctional institutions should base their actions on clear fact-finding, discussing individual responsibility with a thorough understanding of systemic and structural factors.

2. How to Improve External Investigation Mechanisms, Taking the Control Yuan as an Example

   Item	Mai Case	Li Case	Recommended Practice
   Establishing a Professional Team	Given the complexity of this case, a clinical review panel may have been needed to comprehensively review the clinical care received by Mai.	Insufficient data.	The team particularly needs members who understand correctional institutions and possess expertise in the field of healthcare.
   Ensuring the Deceased's Family is Informed	Control Yuan members visited the deceased's family after the investigation concluded, but this was an exceptional case rather than a formal mechanism.	Insufficient data.	Provide the family in a sensitive manner with verified information from the investigation, and provide information on relevant services if the family needs further assistance (such as psychological counseling).
   Custodial Death Case Investigations	Initially only inquired via official letters to check whether Mai suffered bullying or improper discipline, and intended to close the case based on the institution's reply.	Control Yuan members were already alert and immediately initiated an investigation upon learning of the death.	Investigate all death incidents, regardless of whether they are natural deaths, self-inflicted deaths, homicides, or accidental deaths.

Areas for Improvement by Correctional Institutions

1. Notifying Investigative Units

   The Guidelines for Investigating Death in Custody developed by the International Committee of the Red Cross (ICRC) (Guidelines for Investigating Death in Custody) (hereinafter referred to as the "Guidelines") suggest that when a death occurs in a place of detention, the head of the detention facility should initiate a preliminary investigation. Such an investigation should preserve the death scene and related evidence, and record initially visible details of the environment where death occurred. The detention facility should also promptly notify external investigative units.

   In the Mai Case, Mai was found unresponsive in an isolation cell and sent for emergency medical treatment to no avail. The hospital deemed it a case of dead on arrival. Under these circumstances, the isolation cell where Mai was last located should have been regarded as the death scene. However, judging from relevant information, there was no indication that the Taoyuan Juvenile Guidance Home sealed off the scene or notified the police to conduct scene management and evidence collection. It should be noted that, strictly speaking, the Taoyuan Juvenile Guidance Home did this "according to the law." This is because the law only stipulates that when a guidance home student dies within the institution, it "shall immediately report to the prosecutor for examination" (Article 30, Paragraph 1 of the Juvenile Guidance Homes Act), without requiring notification to the police. Furthermore, Ministry of Justice Letter (88) Fa-Chiao-Tzu No. 036082 even explicitly stated that it is only necessary to notify the prosecutor for an autopsy examination, and prosecutors may direct judicial police for investigation if they deem it necessary. But this is problematic, because in practice, prosecutors not only fail to arrive immediately, nor are they responsible for scene preservation and management—those tasks are handled by the police.

   By the time of the Li Case, the problem of notifying investigative units was not adequately improved. As can be seen from the Control Yuan's investigation report, chaos ensued over whether the guidance home should notify the district prosecutors office, the police, or the juvenile court. After confirming the juvenile's death, the Changhua Juvenile Guidance Home immediately notified the district prosecutors office, and only notified the police about an hour and a half later. Moreover, because this case involved a juvenile beating another juvenile to death, whether the juvenile court should be notified and who should notify it became another issue. Amidst the chaos, the juvenile court was simply not notified, drawing criticism from the Control Yuan afterwards.

   What the Changhua Juvenile Guidance Home did better than the former Taoyuan Juvenile Guidance Home was that this time they did notify the police. The police arrived immediately upon receiving the notice, whereas the prosecutor only came the next day to conduct the examination, which demonstrates that notifying the police is necessary. However, relevant regulations had not actually been amended, and there was a lack of rules regarding how correctional institutions and the police should cooperate. Consequently, a controversy arose: after the police arrived, the Changhua Juvenile Guidance Home prevented them from entering to question students and preemptively took statements from the students themselves.

   As for whether the juvenile court should be notified, the Control Yuan's investigation report pointed out that according to the <Concrete Measures for Correctional Institutions to Prevent and Handle Sexual Assault, Sexual Harassment, Sexual Bullying, and Other Bullying Incidents Involving Inmates>, if a juvenile bullies others and commits acts violating penal laws, the competent juvenile court (division) shall be proactively reported to. The Control Yuan faulted the Changhua Juvenile Guidance Home for failing to report to the juvenile court in accordance with the law. To be precise, however, the Changhua Juvenile Guidance Home did report to the juvenile court, albeit with a delay of five days. Therefore, this case involved a failure to report "immediately" after the incident to the juvenile court with jurisdiction over the perpetrator. Yet, reading the regulations cited in the Control Yuan's investigation report from beginning to end, there is no discernible obligation to report "immediately."

   Although the Control Yuan's reasoning may not be entirely accurate, it is crucial that it suggested the Agency of Corrections should convene with relevant agencies to deliberate on handling regulations and reporting operational procedures for similar incidents, thereby fulfilling the obligation of special protection for children and juveniles. This should not merely be a matter of the Agency of Corrections closing its doors to issue official letters or set rules; rather, it should discuss with relevant agencies how correctional institutions should report when a death occurs, what responsibilities each unit has, how to cooperate with one another, and how correctional institutions can best assist relevant external units in conducting investigations.

   Lastly, the Control Yuan also missed another unit that should be notified: the "Control Yuan" itself. Currently, there is no rule requiring deaths in custody to be reported to the Control Yuan. However, considering that the Control Yuan may subsequently transform into a national human rights institution or a national preventive mechanism under the Optional Protocol to the Convention against Torture, such a practice should be incorporated into planning.

2. Preserving Evidence

   The Guidelines point out that detention facilities should collect, preserve, and hand over to investigative units "all" items belonging to the deceased, as well as documents or records related to the deceased, including medical documents such as medical records. The Guidelines do not specifically mention the preservation of video surveillance, but nowadays video surveillance is an important tool for uncovering the truth, and all video footage capturing the deceased's life before death should be fully backed up.

   In the Mai Case, the only surveillance footage preserved was related to the isolation cell within one week of death (January 30 to February 5, 2013), but Mai was only sent to the isolation cell on February 4. Judging from the records, at least since January 30, he had suffered from severe right shoulder pain and vomiting, but there is no surveillance footage to understand how he was treated at that time.

3. Cooperating with Investigations

   The Guidelines point out that detention facilities should allow investigative units to thoroughly inspect the interior of the institution and obtain necessary documents or records. Ideally, investigative units should interview all staff members responsible for the care and management of the deceased, as well as all inmates who witnessed the death, as soon as possible. Detention facilities should inform everyone to cooperate with the investigation rather than monitoring everyone's testimonies. The Guidelines do not mention whether detention facilities should audio or video record their internal investigation interviews, but since audio and video recording equipment is inexpensive nowadays, internal investigation interviews of relevant personnel should not rely solely on written transcripts; interviews should be audio or video recorded throughout to facilitate use by investigative units when needed.

   In both the Mai Case and the Li Case, there were instances or suspicions of monitoring internal personnel's statements. Such occurrences severely damage the credibility of death investigations and must be absolutely avoided. In the Mai Case, the Control Yuan pointed out that the then-Chief of the Discipline Section instructed subordinate personnel to specifically report back the content of their questioning before and after being investigated by the district prosecutors office, monitoring and standardizing their testimonies. The Chief of the Discipline Section even asked colleagues cooperating with the prosecutor's investigation to write reports first and deleted portions of statements he deemed questionable. Furthermore, the Control Yuan pointed out that although the Taoyuan Juvenile Guidance Home claimed to have interviewed Mai's entire class, it consistently provided only partial interviews of some classmates. Yet the provided student interview records, clearly conducted a month after the incident, were remarkably consistent, all stating that no one bullied Mai and that his injuries were caused by push-ups. The Control Yuan believed there may have been concealment of interview records and collusion in testimonies.

   In the Li Case, the Control Yuan pointed out that the Changhua Juvenile Guidance Home immediately conducted individual interview transcripts of juveniles in the same cell after the incident, starting from 18:50 when the ambulance left the facility until around 21:00 that evening. The Changhua Juvenile Guidance Home only notified the police at 21:02, and then refused to let the police enter the guidance home to take statements from the juveniles on the grounds that questioning institutional juveniles required official paperwork procedures which had not yet arrived. Whether the Changhua Juvenile Guidance Home hoped to ensure through preemptive questioning that no information the guidance home wished to keep under wraps would be elicited remains unknown. However, the Control Yuan's skepticism also demonstrates that correctional institutions preemptively conducting internal interview transcripts ahead of external investigative units is a poor practice, as it easily raises concerns about monitoring internal personnel's statements or even covering up the truth. A better practice would be to promptly notify external investigative units so they can interview relevant personnel as soon as possible.

   In both incidents, the guidance homes' internal investigation interviews drew skepticism from the Control Yuan. Had complete audio or video recordings of those internal interviews been preserved, it could at least have helped external investigative units understand whether there were serious flaws in the internal interview process.

4. Truth First, Discipline Later

   A trustworthy death investigation is not about immediately finding those responsible for punishment, but is rooted in clear fact-finding to discuss individual responsibility with a thorough understanding of systemic and structural factors. Here is an event investigation model that is not entirely new, but may not be known to everyone: the "organizational accident model"^[2]. This model suggests that event investigations should avoid purely blaming individuals, and should instead emphasize understanding the system of organizational factors leading to errors, exploring what structural factors affect individual behavior and cause errors to occur, thereby preventing errors from happening again.

   In the Mai Case, no thorough investigation was conducted before claiming that no one had negligence. Subsequently, in the Control Yuan's impeachment case, it was pointed out that the Chief of the Discipline Section placed Mai in solitary confinement on the grounds that his medical condition might disrupt class management, placing Mai in a high-risk situation without care; he also ignored Mai's weakening vital signs and suggestions from other administrators to send him to the hospital, subjectively determining that Mai was faking illness, thereby delaying medical treatment. The Chief of the Health Section paid no attention to Mai's health status and neither personally nor dispatched anyone to understand Mai's condition. The Director failed to fulfill supervisory and management responsibilities, allowing a situation in the guidance home where a student fell ill, was placed in solitary confinement, and died due to a lack of care.

   In the Li Case, grass-roots administrators were swiftly disciplined without clarifying structural factors. The social context at the time of the Li Case differed from that of the Mai Case. At the beginning of the Mai Case, it did not receive sufficient attention; it was through the joint efforts of the deceased's family and legislators that society's attention was drawn to death cases in guidance homes, and Control Yuan members subsequently conducted active investigations, leading to corrective and impeachment cases. When the Li Case erupted, Control Yuan members were already alert and immediately initiated an investigation upon learning of the death. However, hastily disciplining grass-roots administrators in the Li Case was merely an attempt to provide an account under pressure rather than truly confronting the problem.

   In the Li Case, the Changhua Juvenile Guidance Home issued a reprimand once to an administrator surnamed Sun on the grounds that his "sign-in/sign-out patrol times did not match reality," while other personnel had no negligence. However, the Control Yuan pointed out that discrepancies in patrol signing times had nothing to do with preventing this death event or failing to immediately discover and send [the victim] to the hospital. The Control Yuan believed that this incident was related to the subculture in the Changhua Juvenile Guidance Home where "senior residents can bully or manage junior residents"; the failure to immediately discover and send [the victim] to the hospital was related to administrator Sun seeing a gathering of juveniles but failing to pay close attention^[3], as well as equipment disrepair and obsolescence, such as the cell report lights connected to the duty station being out of order for months and cell report warning signals not being connected to the central station (the command center for security duties).

   From this perspective, it can be seen that the Changhua Juvenile Guidance Home's original grounds for disciplining administrator Sun were violations of internal rules, but this was not considered within the causal chain of the death event. Placing the blame solely on administrator Sun was also unreasonable.

Improving External Investigation Mechanisms—Taking the Control Yuan as an Example

Correctional institutions should assist in conducting external investigations; therefore, improving external investigation mechanisms is even more critical. External investigation mechanisms fall into two major categories: judicial investigations and non-judicial investigations. Because the focus of this article is on conducting investigations rooted in the organizational accident model, improving non-judicial investigation mechanisms is the primary focus of this article.

International experts reviewing the second national reports under the Two Covenants also attach great importance to conducting external investigations rooted in the organizational accident model. Reference can also be made to paragraph 52 of the Concluding Observations and Recommendations: The Committee is concerned at the relatively high rate of deaths in custody recently. The Committee recommends that for all cases of death in custody, including cases of apparent suicide, an independent body be established to conduct thorough investigations, and to explore the origins and root causes behind each case in order to prevent future deaths in custody.

In Taiwan, the agency closest to undertaking the aforementioned tasks is the Control Yuan. The Control Yuan possesses investigative powers, can issue investigative reports, and is independent from other supervised Yuan and ministries—these are the basic conditions that an ordinary independent investigation body should possess. In addition to investigative powers, the Control Yuan also holds powers such as corrective measures and impeachment, conditions that other independent investigation bodies may not necessarily have. Considering the Control Yuan's transition into a national human rights institution or becoming a national preventive mechanism under the Optional Protocol to the Convention against Torture—which is not only considered a viable option by international experts but is also currently listed in the government's action plan responding to the Two Covenants' concluding observations—and given that custodial death incidents are major human rights issues and crucial dimensions for examining whether prison operations comply with international human rights covenants, custodial death investigations should also fall within its scope of tasks if the Control Yuan transforms in the future.

Below, this article will introduce a relatively mature non-judicial external death investigation mechanism: the Prison and Probation Ombudsman (PPO) in the United Kingdom^[4], highlighting practices worth referencing and contemplating when the Control Yuan transitions. The broader establishment of a national human rights institution or a national preventive mechanism under the Optional Protocol to the Convention against Torture is not discussed here.

1. Establishing a Professional Team

   For the PPO, establishing a "professional team" is extremely important. The PPO itself does not necessarily need to have served in the criminal justice system, but must be familiar with prison and probation-related issues, capable of independently exercising supervisory and investigative powers, and able to lead an expert team of about a hundred people. This can be seen in the PPO selection criteria published by the UK Ministry of Justice.

   Prior to August 2017, the PPO was held by Nigel Newcomen CBE (appointed in 2011). He holds a Master of Laws from the London School of Economics, previously served as a Community Service Officer in the probation service, and has frontline practical experience. Having risen through the ranks, he also participated in numerous prison service policy-making decisions. He had 20 years of prison-related service experience, which led some to question his independence. Elizabeth Moody, who temporarily took over as PPO after August 2017, served as Deputy Ombudsman at the PPO for quite a long time and is familiar with related operations.

   In contrast, because the Control Yuan in Taiwan handles an exhaustive array of matters, it is difficult to demand that Control Yuan members meet qualification requirements tailored to the knowledge and capabilities needed for external prison investigations. If the Control Yuan is to transform into a national human rights institution in the future, or become a national preventive mechanism under the Optional Protocol to the Convention against Torture, then the qualification requirements for Control Yuan members in the Organic Act of the Control Yuan must be amended, and members nominated for different human rights issues should be familiar with and possess relevant knowledge and capabilities in those human rights fields.

   Beyond requirements for the leader heading the investigative team, whether the underlying staff is sufficient in number and possesses professional knowledge and skills regarding custodial death investigations is also a vital component. Regarding PPO investigators, nearly 40 full-time staff members across four teams are responsible for custodial death investigations. Between 2016 and 2017, the PPO team intervened and investigated all 361 death incidents (including natural and non-natural deaths). The PPO website provides profiles of staff backgrounds, showing that 53% previously had no work experience related to prisons, probation, or foreign immigration detention, while 47% had relevant work experience. Among those with relevant experience, some served in managerial positions in adult prisons, juvenile correctional institutions, probation offices, etc., while others were non-managers, and some had worked in policy planning or casework within relevant decision-making departments. As for the background categorization of those without criminal justice system work experience, the website does not elaborate. Having nearly half of the staff with criminal justice system work experience, while making the PPO team relatively familiar with correctional facilities, has also led to criticisms regarding a lack of independence. This is actually somewhat of a dilemma: external investigations require a certain understanding of the system to avoid being hoodwinked, making it important to have members with relevant experience on the team. However, finding individuals who have worked internally yet can maintain independence and criticality may be quite rare.

   Additionally, to meet the professional knowledge requirements of death investigations in the healthcare field, the PPO cooperates with the National Health Service in England (National Health Service England, an organization similar to Taiwan's National Health Insurance Administration responsible for public healthcare) to conduct independent clinical reviews. The purpose of a clinical review is to understand the clinical care received by the deceased while in detention. It aims to understand "how" and "why," rather than to assign blame. Questions to be answered include: When and how did the inmate die? What were the root causes of the death? Was the clinical care provided to the inmate up to the standard expected in the community? Are there any lessons to be learned? What policies and procedures were involved? Was there an opportunity to prevent the death? Are there good practices to reference? Depending on the complexity of the case, a clinical review may be conducted by a single physician based on written records and reports, or by a panel that not only reviews written materials but also interviews healthcare workers, thereby producing a clinical review.

   If the Control Yuan wishes to effectively conduct custodial death investigations, having members on the investigative team who understand correctional institutions yet can critically review their actions, as well as members with professional knowledge in the healthcare field, will be vital. Judging from the Mai Case, introducing individuals with professional knowledge in healthcare to assist in death investigations is particularly necessary. In the Mai Case, Control Yuan members consulted Dr. Lai from National Taiwan University, who raised some points of doubt regarding Mai's injuries and cause of death. This shows that Control Yuan members recognized that Mai's death required medical professionals to assist in review. However, given the complexity of the Mai Case, consulting individual doctors may no longer suffice; a clinical review panel may have been necessary to comprehensively review the clinical care Mai received.

2. Ensuring the Deceased's Family is Informed

   For the PPO, ensuring that the deceased's family is informed throughout the investigation process is an important task. The PPO team includes a position called the "family liaison officer," who is responsible for communicating with the deceased's family, providing verified information from the investigation in a sensitive manner, and offering information on relevant services if the family needs further assistance (such as psychological counseling).

   PPO reports are divided into stages. One type is the initial report, which is provided to the deceased's family and other relevant parties for feedback after its release. The deceased's family can provide comments on factual accuracy. Once the final report is completed, it is also provided to the deceased's family.

   After the investigation of the Mai Case concluded, Control Yuan member Wang Mei-yu and two investigative secretaries visited the grandmother of the juvenile surnamed Mai, but this was a highly exceptional practice. Generally speaking, the Control Yuan values confidentiality in the investigative process, but does not place emphasis on building relationships with the deceased's family. From the standpoint of independence, this is certainly good; however, if the goal is to make investigations more trusted by the deceased's family and make them feel valued or respected during the investigation, this is an important practice.

3. Initiating Investigations for All Custodial Death Cases

   The PPO investigates all custodial death cases, including natural deaths, self-inflicted deaths, homicides, and accidental deaths^[5]. In principle, the PPO does not investigate deaths of persons who have already been released, but if a recently released person dies and there are issues worth reviewing and improving, the PPO may also conduct an investigation^[6].

   Currently, the Control Yuan does not intervene in all custodial death cases; natural death cases in particular^[7] receive relatively little attention. In the Mai Case, the Control Yuan's initial investigation focus was solely on whether Mai suffered bullying or improper discipline; after official letters of inquiry brought a reply of no substantiated evidence, it originally intended to file the case away. But even if Mai's death was a natural one, wouldn't investigating the healthcare issues in this case be important?

   Taking as an example the PPO's investigation into the death of 16-year-old Daniel Adewole caused by an epileptic seizure^[8], Adewole suffered from epilepsy and, after being sent to a young offender institution, had an important medical appointment cancelled by the institution on the grounds of security. He subsequently suffered a seizure in his cell; the parole officer who discovered him did not enter to provide emergency aid, but instead called for help and waited for a prison officer to open the cell door before entering to administer aid. The PPO report pointed out that the institution's justification of "custodial security" was actually just that the juvenile and his parents knew the time of that medical appointment, with no other serious security considerations. Therefore, it recommended that if a juvenile's medical appointment is cancelled due to security considerations, there should be highly justified and documented security reasons, confirmed by a healthcare worker not to impair the juvenile's health. Furthermore, although patrol officers are generally not permitted to enter cells without authorization, exceptions should be made when a juvenile faces life-threatening danger. In this case, the patrol officer did not understand the juvenile's health condition or how to respond; there should be relevant mechanisms to inform institutional staff of a juvenile's health status, what to do in emergencies, or other precautions to note.

What Can We Do Starting Now?

Faced with insufficient existing resources and the distant prospect of the Control Yuan's transformation, we must still think pragmatically: Starting now, how can custodial death investigation mechanisms be progressively improved?

1. Even in situations where external investigations cannot cover every custodial death case, the Agency of Corrections should at least publish the annual number of custodial deaths, categorized by natural deaths, self-inflicted deaths, homicides, accidental deaths, and others for statistical enumeration. Furthermore, if internal investigation reports are produced, their contents—except for personal data and portions whose publication might compromise prison security—should also be published online. This will allow outsiders to understand custodial death trends and how correctional institutions handle and improve upon them.
2. If the Agency of Corrections has not yet discussed with relevant investigative units how correctional institutions should report when a death occurs, what responsibilities each unit has, how to cooperate, and how correctional institutions can best assist external units in conducting investigations, cross-unit coordination and communication meetings should be convened as soon as possible. The Control Yuan should be among the participants in these discussions.
3. Improvements regarding evidence preservation and cooperation with investigations do not involve massive resource deployment and can be undertaken immediately by the Agency of Corrections.
4. Request the Ministry of Health and Welfare to assist in establishing a clinical review system for custodial death incidents. This can be used to assist both internal investigations by correctional institutions and investigations by the Control Yuan.
5. Regarding ensuring the deceased's family is informed, while it is unlikely that the Control Yuan will immediately establish "family liaison officers," correctional institutions should grant the deceased's family the right to reasonably obtain copies of relevant documents or records concerning the deceased while in custody, including medical documents such as medical records. Relevant data from prosecutor examinations or forensic autopsies should also be provided promptly to the deceased's family, and explained to them in plain language if possible. Sometimes, simply knowing how a family member died, or knowing that a family member's death is being taken seriously, brings comfort to the family.
6. If the Control Yuan has limited resources and cannot investigate all custodial death cases, it should at least intervene and investigate all death cases of juveniles in correctional institutions or judicial placement facilities. As for adult death cases, the Control Yuan already consciously intervenes in deaths caused by improper security (such as the death case of Lin Wei-hsiao); the next category that might warrant special attention is self-inflicted deaths. When self-inflicted deaths occur, correctional institutions have historically often strengthened security measures to prevent self-harm, such as banning CDs if someone committed suicide using a CD. Nowadays, mental health care is gradually gaining emphasis, and reviews often focus on strengthening counseling. However, there is still insufficient focus on improving prison environments, rules, and policies, or even examining whether certain inmates should never have been sent to correctional facilities in the first place. As an external investigative unit, the Control Yuan is particularly well-suited to examine overall policies, rules, and environments, and to propose reform recommendations, thereby remedying the shortcomings of internal prison investigations and reviews.

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