12th November 2012


INQUEST has today sent the coroner’s Rule 43 report to the relevant government ministers to ensure the widest possible national learning from the death of Sean Rigg.

HM Coroner Dr Andrew Harris, recently sent his Rule 43 report of 22 October 2012 to Hickman and Rose, the solicitors for the Rigg family. It identifies critical learning in relation to Lambeth mental health care services and the Metropolitan Police Service (MPS) policing response to those with mental illness.

The Coroner stressed that, “despite the passage of four years since Mr Rigg died, there is still a lack of clarity and incomplete understandings of the roles of different organisations and when they should communicate and act together – especially in an emergency”.

Concerning the failure by SLAM to conduct an urgent Mental Health Act assessment following signs that Sean Rigg was relapsing, Dr Harris identified apparent gaps in “knowledge, awareness, teamwork, joint working and policing” which created a risk that other deaths could occur.

Concerning the police response, after recalling that the inquest identified clear inadequacies in mental health training for both MPS call handlers and police officers, Dr Harris said:

“I cannot be sure that staff and officers have an adequate understanding of mental health needs… There is a need for a review of the information and training with respect to the mental and physical health needs of mentally ill prisoners throughout the Metropolitan Police.”

His detailed list of recommendations include:

reviewing knowledge and training of all those who may be involved with MHA assessments to ensure proper understanding of powers available and timeliness of MHA assessments of a person who may be relapsing;

  • establishing joint protocols between SLAM, LBL and MPS for meeting the needs of those presenting with urgent psychiatric problems which require interagency co-operation;
  • addressing apparent weaknesses in the way the MPS handles those with mental illness in custody, including around training, the adequacy of mental health procedures, the role of leadership and decision making in restraint situations, understanding the options available for a person who may have mental illness, including use of a place of safety

A response to the recommendations is required within 56 days of the report being sent.

INQUEST has today alerted the relevant Ministers to the contents of the report.

Casale Review 

The IPCC have today confirmed the team who will be responsible for conducting the external independent review of the IPCC investigation into the death of Sean Rigg.  The review will be lead by Dr Silvia Casale, who was until recently the president of the European and UN committees for the prevention of torture and inhuman and degrading treatment.

This is the first ever external review of an IPCC investigation of a death following police contact.  As well as addressing individual learning from Sean’s case, the IPCC has stated that the review will inform the wide scale review they are currently conducting into its investigation systems and approach to deaths following police contact.

Marcia Rigg, Sean Rigg’s sister said:

“We’re very pleased that the coroner has made such wide-ranging recommendations.  Sadly since Sean’s death there have been other people who are mentally unwell who have died at the hands of the police.

“It is essential that all the failings identified at Sean’s inquest are acted upon, crucially so that this does not happen to any more families.

“Meanwhile, we welcome the appointment of the Casale review panel so the review into the woeful IPCC investigation can finally get under way.”

Deborah Coles, co-director of INQUEST said:

“We want to ensure that the report’s strong recommendations do not disappear into the ether as they are a valuable learning tool to safeguard lives in the future. The jury’s findings and the Coroner’s recommendations need to be disseminated to all police forces and mental health agencies across the country for their consideration and action.

“It is crucial that Ministers review the Coroner’s report so that the lessons are learned and changes made nationally: we now await assurances from the Home Secretary and Health Secretary that this will happen.

“The external review of the IPCC investigation presents a unique opportunity to critically examine the way the IPCC approaches investigations into contentious deaths. Too often these investigations have revealed systemic failings in the IPCC approach and have resulted in a lack of family and public confidence.”


Notes to editors:

  1. Full details of the IPCC review panel can be found on the IPPC website.