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| Deaths in custody lessons are being ignored, says charity | Deaths in custody lessons are being ignored, says charity |
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| Lessons learned from deaths in police and prison custody are being repeatedly ignored or lost because there is no official body to enforce them, according to a charity that supports bereaved families at inquests. | Lessons learned from deaths in police and prison custody are being repeatedly ignored or lost because there is no official body to enforce them, according to a charity that supports bereaved families at inquests. |
| Many coroners' rule 43 reports, designed to prevent accidents and save lives, have negligible impact because there is no authority charged with ensuring compliance, the organisation Inquest has warned. | Many coroners' rule 43 reports, designed to prevent accidents and save lives, have negligible impact because there is no authority charged with ensuring compliance, the organisation Inquest has warned. |
| Its report is launched as deaths in English and Welsh prisons are on an upward trend – having dipped to 155 in 2006, the annual number of fatalities climbed to 189 last year. | Its report is launched as deaths in English and Welsh prisons are on an upward trend – having dipped to 155 in 2006, the annual number of fatalities climbed to 189 last year. |
| Coincidentally, the ancient office of coroner, which dates to the Norman conquest, is undergoing an overhaul with the appointment this summer of the first chief coroner, Judge Peter Thornton QC. | Coincidentally, the ancient office of coroner, which dates to the Norman conquest, is undergoing an overhaul with the appointment this summer of the first chief coroner, Judge Peter Thornton QC. |
| Thornton, who presided over the inquest last year into the death of Ian Tomlinson during the G20 protests in 2009, has suggested developing "cadres" of investigators specialising in military and custody fatalities. He attended the launch of Inquest's report. | Thornton, who presided over the inquest last year into the death of Ian Tomlinson during the G20 protests in 2009, has suggested developing "cadres" of investigators specialising in military and custody fatalities. He attended the launch of Inquest's report. |
| The study, Learning from Death in Custody Inquests, is backed by the former chief inspector of prisons Lord Ramsbotham who told the Guardian: "For years, large numbers of people have been frustrated and worried by the fact that nothing which has been learned, either good or bad, appears to have been used to prevent further [deaths]. I would have hoped the government would be leading this from the top down [but it appears to be] bubbling up from practitioners." | The study, Learning from Death in Custody Inquests, is backed by the former chief inspector of prisons Lord Ramsbotham who told the Guardian: "For years, large numbers of people have been frustrated and worried by the fact that nothing which has been learned, either good or bad, appears to have been used to prevent further [deaths]. I would have hoped the government would be leading this from the top down [but it appears to be] bubbling up from practitioners." |
| Ramsbotham is chairing an independent inquiry into the use of restraint techniques in relation to the death of the asylum seeker Jimmy Mubenga, who was being deported by G4s guards at Heathrow airport in 2010. The report is due this autumn. | Ramsbotham is chairing an independent inquiry into the use of restraint techniques in relation to the death of the asylum seeker Jimmy Mubenga, who was being deported by G4s guards at Heathrow airport in 2010. The report is due this autumn. |
| The peer has pointed out that previous warnings about the dangers of restraint methods leading to so-called positional asphyxia were not adopted sufficiently. He called for the wider "dissemination of lessons learnt from restraint deaths". | The peer has pointed out that previous warnings about the dangers of restraint methods leading to so-called positional asphyxia were not adopted sufficiently. He called for the wider "dissemination of lessons learnt from restraint deaths". |
| The charity Inquest has been monitoring deaths in custody for 30 years. "One of the striking features of this work," the report says, "has been our repeated experience of attending inquest after inquest where the same issues are identified as possibly contributing to a death. | The charity Inquest has been monitoring deaths in custody for 30 years. "One of the striking features of this work," the report says, "has been our repeated experience of attending inquest after inquest where the same issues are identified as possibly contributing to a death. |
| "The more effective use of narrative verdicts [explaining precisely what occurred] and coroners' rule 43 reports is overwhelmingly likely to assist in the saving of lives. [But] the existing system is flawed. | "The more effective use of narrative verdicts [explaining precisely what occurred] and coroners' rule 43 reports is overwhelmingly likely to assist in the saving of lives. [But] the existing system is flawed. |
| "The lessons to be learned from the contents of these of these verdicts and reports are far too frequently lost: they are analysed poorly or ignored; misunderstood or misconstrued; dissipated or dismissed." | "The lessons to be learned from the contents of these of these verdicts and reports are far too frequently lost: they are analysed poorly or ignored; misunderstood or misconstrued; dissipated or dismissed." |
| There is no official body charged with enforcing compliance with recommendations made in rule 43 reports, according to the charity. It said: "Once an inquest is over there is nothing 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 2004." | There is no official body charged with enforcing compliance with recommendations made in rule 43 reports, according to the charity. It said: "Once an inquest is over there is nothing 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 2004." |
| Deborah Coles, co-director of Inquest and co-author of the report, said: "The same systemic failings repeat themselves with depressing regularity at inquests into deaths in custody. | Deborah Coles, co-director of Inquest and co-author of the report, said: "The same systemic failings repeat themselves with depressing regularity at inquests into deaths in custody. |
| "With the incorporation of deaths in custody into the Corporate Manslaughter Act [2007] 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." | "With the incorporation of deaths in custody into the Corporate Manslaughter Act [2007] 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 Inquest report mentions Styal prison and young offender institution in Cheshire, which houses female inmates. "Six women died there in the 12 months between August 2002 and August 2003," it says. | The Inquest report mentions Styal prison and young offender institution in Cheshire, which houses female inmates. "Six women died there in the 12 months between August 2002 and August 2003," it says. |
| "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." | "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." |
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