30th October 2017

The Independent review of deaths and serious incidents in police custody by Dame Elish Angiolini has been published by the Home Office today. It is the first and only review of policing practises and related processes following police related deaths. The report offers the government a blueprint for change to urgently implement in the face of numerous recent concerning deaths.

It makes over 100 evidence based recommendations, which are intended to be a pragmatic way forward. These include important recommendations on:

  • Access to justice for families, including through non-means tested legal representation for bereaved families from the earliest point following the death.
  • Strengthening systems and structures of accountability, holding the police to account at an individual and corporate level.
  • National Oversight and learning from deaths, such as through an ‘Office for Article 2 Compliance’ which would monitor and report on recommendations arising from deaths.
  • Improved investigation, including through the phasing out of Ex-police officers as lead investigators within the IPCC.
  • Tackling discrimination, through recognition of the disproportionate number of deaths of BAME people following restraint and the role of institutional racism, both within IPCC investigations and police training.
  • Better treatment of vulnerable people, including through proper resourcing of national healthcare facilities to accommodate and respond to vulnerable people in urgent physical or mental health need coming into contact with the police.
  • An end to delay, in which Article 2 related cases should be dealt with in the same time scales as a civilian homicide case.

A full policy briefing which highlights key recommendations in depth, can be found  here. The review in full can be found here.

The review was commissioned by Theresa May, then Home Secretary, after meeting the families of Olaseni Lewis and Sean Rigg, both of whom died following restraint by police officers whilst suffering mental ill health. Dame Elish Angiolini is the former Solicitor General and Lord Advocate in Scotland, and conducted the review. INQUEST’s Director Deborah Coles was Special Advisor to the Chair and INQUEST facilitated meetings for Dame Elish to hear directly from a large number of families with varying experiences, as well as groups of lawyers who regularly represent families.

During the 10 month wait for the review to be published there have been a number of concerning deaths following police contact. The deaths of Rashan Charles and Edson Da Costa in particular have reignited widespread public concern. Since January we are aware of at least eight deaths involving restraint or taser and other use of force, and five deaths of people who ‘became unwell’ or were found unresponsive while in custody. There have also been a number of conclusions in police misconduct hearings and trials that have led bereaved families to question the state of learning and accountability processes.

Deborah Coles, director of INQUEST said:
“This seminal report is an indictment of the failing systems of investigation, learning and accountability which follow the long running issue of deaths in police custody. It is a hugely important opportunity to bring about changes that could save lives.  The recommendations extend to the police service, health service and justice systems and are a blueprint for change that would benefit everyone. The value of this report must ultimately be judged by the changes it brings about.

The vital need for action is revealed by recent restraint related deaths of young black men and vulnerable people with mental ill health who have died in police cells since the report was finalised. We call upon the Government to urgently respond with a programme of action to implement the recommendations in full.”



For further information, please contact Lucy McKay on 020 7263 1111 or [email protected]

• The final review can be found on the Home Office website here and the government response can be found here.

• Our full policy response can be found here.

• You can watch the full press conference with Deborah Coles, Dame Elish Angiolini and families affected on our Youtube here.

• Dame Elish Angiolini is the former Solicitor General and Lord Advocate in Scotland, and the principal of St Hugh’s College, Oxford.

• On 3 November there will be a second reading of ‘Seni’s Law’, a draft Bill brought forward by Steve Reed MP on Mental Health and Use of Force. More info here.

• RECENT DEATHS: In total we are aware of 36 deaths following police contact in 2017, some of which are outside the remit of the review, including 12 pursuit and road traffic incident related deaths and 5 shootings. Within the remit of the review are: six restraint related deaths, two deaths involving other use of force such as tasers, and five deaths of people who “became unwell” or were found unresponsive while in custody.

- Officers involved in the death of James Herbert found not guilty of misconduct.
- Officers involved in the death of Olaseni Lewis cleared of misconduct.
- Officers involved in the death of Adrian Macdonald found guilty of lesser charge of misconduct (not gross) for failing in their duty of care.
- Officers found guilty of misconduct following death of David Fournier D'Albe, with no further action.
- Officers found not guilty of perjury at criminal trial in relation to the death of Kingsley Burrell.
- Officers found not guilty of manslaughter following the death of Thomas Orchard.