1st October 2012

A week after the appointment of the Chief Coroner, HHJ Peter Thornton, and at a time of renewed interest in the coronial system following the publication of the report of the Hillsborough panel, INQUEST launches a groundbreaking new report Learning from Death in Custody Inquests: A New Framework for Action and Accountability. The 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.

Recent death in custody inquests¹ have shown how vital the inquest process is in the identification of failings in custodial health and safety.  Yet once the inquest is over there is nothing in place to make sure those failings are addressed and acted upon by the relevant authority.  The Prisons and Probation Ombudsman’s recent annual report noted the ‘deeply troubling’ rise in the number of deaths in custody in the past year, the highest since 2004².

The report analysed 50 rule 43 reports received by INQUEST between 2007 and 2009.  The analysis reveals a series of trends and patterns that show that the same issues are consistently identified as possibly contributing to the death.  These include such issues as failures in communication and recording procedures, healthcare treatment and resources, treatment of those identified as being at risk of self harm, training, cell design, and mental health issues among others³.

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.

Deborah Coles, co-director of INQUEST and co-author of the report said:

“INQUEST’s frustration is with how the same systemic failings repeat themselves with depressing regularity at inquests into deaths in custody.

“A proactive post inquest strategy in response to verdicts and reports and a more co-ordinated and active response by the investigation, inspection and regulation bodies can not only avert future deaths but improve standards of custodial care and ensure that the human rights of detainees are protected. The more effective use of narrative verdicts and Coroners Rule 43 reports is overwhelmingly likely to assist in the saving of lives.

“The appointment of the Chief Coroner presents us with a unique opportunity for real, fundamental reform.

“With the incorporation of deaths in custody into the Corporate Manslaughter Act there is the need for a statutory mechanism to be put in place that ensures proper monitoring and analysis of narrative verdicts and rule 43 reports to see whether action has been taken to rectify dangerous practices and systems identified during an inquest. This is an important instrument for accountability.”

The report was discussed at a high profile seminar held at Matrix Chambers on 27 September and attended by the Chief Coroner, Lord David Ramsbotham, leading lawyers and representatives of the inspection, investigation and regulation bodies.

Lord David Ramsbotham said:

“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.”

The Chief Coroner said:

“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.”


Notes to editor

  1. http://www.inquest.org.uk/press-releases/press-releases-2012/inquest-jury-finds-prisoner-died-following-neglect-at-parc-prison



  1. Prisons and Probation Ombudsman Annual Report 2011-2012  http://www.ppo.gov.uk/annual-reports.html
  2. A graphic example of this is that of HMP & YOI Styal. Six women died there in the 12 months between August 2002 and August 2003. At the conclusion of an inquest into a previous death in Styal prison in 2001 the coroner made a rule 43 report about the need to set up a detoxification regime for women withdrawing from drugs. This was not implemented until after the sixth death had occurred, which was over two years after his report was issued.
  3. The report is available for download here