This groundbreaking report highlights the serious flaws in the learning process following an inquest into a death in custody or following contact with state agents.

In the report INQUEST’s co-directors Deborah Coles and Helen Shaw argue that the absence of a mechanism to capture and act upon the rich seam of data available from well conducted and costly inquests leads to unnecessary further loss of life. While the coronial service can and does make a vital contribution to the prevention of deaths that input is being undermined, as there are no established mechanisms for monitoring compliance with and or action taken in response to failings identified in narrative verdicts or in response to rule 43 reports. Moreover, there is no obligation for a coroner even to produce a rule 43 report.

Learning is lost by: the inconsistent approach by coroners to the use of their powers to report matters of concern to the relevant authorities; the lack of analysis, publication and dissemination of the reports or narrative verdicts across custodial sectors and the lack of transparency and accountability of the detaining agencies about action taken to rectify identified and dangerous systemic problems.

This presents an overwhelming case for the creation of a new mechanism in the form of a central oversight body tasked with the duty to collate, analyse critically, publish and report publicly on the accumulated learning from coronial narrative verdicts and rule 43 reports and a more co-ordinated response by the regulation investigation and inspection bodies once an inquest has taken place.

This short but well-argued report provides a valuable contribution to the important debate on deaths in custody and how they may be avoided in the future.”

HHJ Peter Thornton, the Chief Coroner for England and Wales

I warmly welcome this excellent report.  I am glad that it coincides with the appointment of the Chief Coroner, Judge Peter Thornton, because his presence and direction will be vital if the overdue improvements, so clearly outlined in the report, are to be brought about.”

Lord David Ramsbotham

This excellent report highlights the significance of Rule 43 reports in preventing further deaths and in ensuring that the State’s duties under Article 2 are properly discharged. Its recommendations for improvement to the system of Rule 43 reporting will no doubt be of considerable interest to those concerned to see that the power to prepare such reports can be, and is, used to the best effect.

Karon Monaghan QC

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