The Commission has received an intimation from the Superintendent, Sub Jail, Kamakhya Nagar, Odisha that UTP Nandu @ Sanjay Behra went to sleep at 10.30 PM on 9.10.2013 inside ward No. 3 of Sub Jail, Kamakhya Nagar after watching TV. Next morning at 6.00 AM on 10.10.2013, he was found in an unconscious state so he was referred to SD Hospital, Kamakhya Nagar where the duty officer declared him dead. In this regard, a complaint has been received in the Commission from Smt. Sangita Swain, Secretary, Human Rights Watch alleging that the prisoner Sanjay Behra was remanded to judicial custody in case No. 261/13 u/s 394/342/186 IPC PS Parjang in a severely injured condition. It has also alleged that the UTP died due to severe internal injuries. Accordingly, the Commission took cognizance and registered a case vide No. 2385/18/4/2013-AD and this file with the instant case i.e. case No. 2358/18/4/2013-JCD. Pursuant to the directions of the Commission, all the relevant reports relating to the death of the deceased prisoner was received. Proforma for health screening of prisoners reveals that the deceased was not suffering from any disease at the time of admission in jail but he had multiple injuries all over his body. The perusal of the treatment record reveals that the deceased was treated for multiple abrasion injuries, sprain, URT, backache etc. from 3.6.2013 to 19.9.2013 in jail hospital. As per the Inquest Report, no external injury was present on the body of the deceased. The probable cause of death in the opinion of the witnesses was not known. The post mortem report indicates that no ante mortem external or internal injury was found on the body of the deceased. The cause of death could not be ascertained and viscera was preserved for chemical analysis. As per viscera examination report, no poisonous substance was detected in the visceras of the deceased. The board of doctors opined that on reviewing the case in the light of FSL report and post mortem findings the deceased Nandu @ Sanjay Behera would appear to have died of undetermined, natural consequence. The Magisterial enquiry was conducted by the Executive Magistrate, Kamakhya Nagar. As per the Magisterial enquiry report, the subject Nandu @ Sanjay Behera entered the jail on 3.6.2013 and at that time, he had multiple injuries at his back, right arm and both the legs. He was given regular treatment by the jail doctor on 19.6.2013 and his health condition appeared to be stable. Since then the prisoner never made any health/disease related complaint. Co-inmate Santanu Patra stated that at 8.30 PM on 9.10.2013, the subject was sneezing and whispering while asleep. He made the deceased calm down by touching his body. Thus the UTP clamed down and went into deep sleep. Next morning on 10.10.2013 at 6.00 AM, all the co-inmates woke up but the deceased was found in unconscious state. Consequently, the jail doctor came and examined him at 6.10 AM and found his pulse very feeble. At about 6.25 AM on 10.10.2013, the jail staff took him to SD Hospital, Kamakhya Nagar where the doctor declared him dead after examination. The Ld. Magistrate concluded that the prisoner died due to sudden failure of vital organs and there appeared no laxity on the part of the jail administration in providing him the proper treatment. The magisterial enquiry report does not speak about the of injuries found on the body of the deceased at the time of his admission in the jail. Moreover, the family members were also not associated by the Magistrate during the course of magisterial enquiry. The Commission closely examined the aforesaid reports and found that the Enquiring Magistrate has not formed any opinion on the cause of injuries noticed on the person of the deceased. Therefore, the DM and SP, Dhenkanal, Odisha were directed to clarify the said fact. In response to the Commission's direction, a joint enquiry report was submitted by the DM, Dhenkanal and the Superintendent of Police, Dhenkanal which reveals that the deceased Nandu @ Sanjay Behera was arrested on 3.6.2013 at 800 AM in connection with Dhenkanal Parjang PS Case Crime No. 106/13 u/s 186/294/342/394/506 IPC. The report further reveals that the deceased while trying to escape after committing robbery, the local people come to the spot and chased and caught hold of the accused. Unfortunately the accused fell down and sustained bodily injuries. The medical officer of CHC, Parjang after examining the accused stated that the injuries sustained by the accused are simple in nature and were caused by hard and rough surface. The IOs of the case forwarded the accused Nandu @ Sanjay Behera to the court of SDJM, Kam Nagar along with statement u/s 161 Cr. P.C., arrest memo, inspection memo and injury report. On his admission, he was treated at Jail Hospital for the injury on his back, right arm, left leg and right leg. Subsequently, the Commission referred the case record to the Expert on its Panel for his opinion. After examining the materials on record, the expert held his opinion as follows:- "I have perused the records pertaining to the custodial death of undertrial prisoner Nandu @ Sanjay Behera aged about 28 years on 10.10.2013. As per records, the deceased was lodged in the jail from 3.6.2013. At the time of his entry, as per the health screening document, he had 'multiple injuries all over the body'. In the prison treatment record, it is mentioned that he had multiple abrasion for which he was given treatment. Again on 5.6.2013, he complained pain all over the body for which he was given pain killers. On 11.6.2013, he was given thrombophob gel (containing heparin) probably to treat the bruises. On 11.7.2013, 12.7.2013 and 16.8.2013, he got treatment in the form of pain killers. On 24.8.2013, he was diagnosed with Upper Respiratory Tract Infection for which he was given antibiotics. On 14.9.2013 and 19.9.2013 he was given pain killers. On 10.10.2013 he was found in an unconscious state and after examination was declared dead." According to the expert, the following shortcomings were noticed by him:- 1) It is noted that the Medical Officer has vaguely mentioned the presence of multiple external injuries. It is imperative to note that in any Medico Legal Document, the injuries should be sequentially noted describing the type of injury, its dimension, its location on the body in relation to the anatomical land mark and its estimated aged. This omission by the Medical Officer has compromised quality of the Medico Legal document, without mentioning the presence and extent of the injuries sustained by the deceased prior to the admission to the jail. 2) It is important to note that the Medical Officer in the prison has not mentioned basic clinical observations before coming to the diagnosis and dispensing treatment. Hence it is not possible to comments on the adequacy of the treatment. 3) The autopsy examination was carried out and it was noted that almost all the internal organs were congested. At this stage the DVD containing the video recording of the deceased was reviewed. It is important to mention that the autopsy surgeons did not dissect the coronary vessels at all. The presence of any blockage in the coronary vessels is the vital part of any medico-legal autopsy especially in cases of sudden death. Further with negative FSL report, the cause of death remained inconclusive. After a thorough analysis of the aforesaid reports and the opinion made by the Expert, the Commission finds the following facts emerging from the record:- (a) The accused Nandu @ Sanjay Behera was arrested on 3.6.2013 at 800 AM in connection with Dhenkanal, Parjang PS Case Crime No. 106/13 u/s 186/294/342/294/506 IPC. (b) On 30.6.2013, the accused Nandu @ Sanjay Behera while managing to escape after committing robbery, the local people chased and catch hold the accused. Unfortunately, the accused fell down and sustained bodily injuries. (c) The injuries sustained by the accused are simple in nature and were caused by hard and rough surface. (d) No definite opinion was given regarding final cause of death in the post mortem report. (e) The autopsy surgeons did not dissect the coronary vessels at all. The presence of any blockage in the coronary vessels in the vital part of any medico-legal autopsy especially in cases of sudden death. Further with negative FSL report, the cause of death remained inconclusive. From a close analysis of the materials on record, it is established that there was negligence on the part of the Prison Medical Officer. The negligence shown by him as indicated above is a clear violation of the human rights of the prisoner. Therefore, the Chief Secretary to the Government of Odisha is directed to show cause u/s 18 (a) (i) of the PHR Act, 1993 as to why a monetary compensation of Rs. 1 Lakh should not be recommended to be paid to the next of the kin of the deceased prisoner within six weeks. The Commission feels it necessary to direct the Principal Secretary, Health and Family Welfare, Government of Odisha to sensitize the Medical Officers (Prisons) by organizing Special Training Camps in collaboration with Forensic Medicine Department of the nearest Medical College so that the experiences gathered at the Camp may go a long way in channelizing their resources for proper medical administration in the prisons.