In September 2023, the Independent Advisory Panel on Deaths in Custody published a new report, “More Than a Paper Exercise”, on a topic of particular interest to me – the publication, dissemination and use (or not) of Preventing Future Death (PFD) reports from Coroners in England and Wales. A little background for those who may be unfamiliar —
There is a Chief Coroner for England and Wales – this is a senior judge, appointed to a statutory position to oversee all aspects of His Majesty’s Coronial system. This includes the training of Coroners, oversight of inquest processes and collation and publication of PFD notices, where they have been issued by a coroner. Each year, the Chief Coroner publishes an annual report and of course, within all of the inquests conducted each year, a number of them are deaths in state custody – police, prisons and psychiatric detention.
This new report covers the PFD issue and makes the argument that publication, dissemination and use of these important statutory documents needs to amount to “more than a paper exericse”. The phrase comes from research conducted with families of those who have died, where they have been frustrated to find some PFD notices go not receive a reply for the organisation to which they are sent (despite a direction to reply within 56 days) and many recommendations made by Coroners to prevent future deaths are not implemented.
SUMMARY RECOMMENDATIONS
The report calls for a number of things (see pages 4/5 for all eighteen recommendations) and some of these relate to the agencies to which PFDs are sent.
Majny things of interest to me within this —
- Recommendation 3 – MoJ is being asked to provide resource to allow a specific annual review of deaths in custody. The Coroner’s existing annual review is not death-in-custody specific.
- Recommendation 4 – the Chief Coroner should be resourced to allow for publication of inquest jury conclusions, even where no PFD is issued. Currently, the PFD is published on the Chief Coroner’s website, but the actually record of inquest with jury conclusions is not recorded. Having seen a few hard copies of such things, there is also learning within and it no doubt increases transparency about what juries found agencies actually did or did not do.
- Recommendation 5 – that an independent organisation should be created to investigate deaths in mental health settings where patients are formally or informally detained. We have an indepedent body to investigate deaths in police custody or in prison custody, but nothing for psychiatric detention.
- Recommendation 7 – a call for more detailed, specific and evidence-based responses to PFD notices. This may seem surprising but I’ve seen PFD responses, which are often uploaded to the Chief Coroner’s website, which made me wonder whether the author of the reply was actually aware of the inquest evidence.
- Recommendation 8 – I’ve called for and questioned this one before: a recommendation to ‘horizontally’ share PFD notices with equivalent organisations. IE, where police force X receives a notices, they should share this with the other 42 police forces in England and Wales and arguably, why not Scotland and Northern Ireland as well? There are many similarities between certain deaths in custody and it might well be wondered why lessons weren’t learned, but we often see that those similar tragedies occurred in different police forces. Would police force Y even be aware of the PFD notice received by police force X three years ago – often not, no.
- Recommendation 10 – the charity Inquest has called for a ‘national oversight mechanism’ to ensure the direction and concerns of Coroners is implemented or overseen as to why it’s not implemented. This report calls for “more effective oversight of the sharing, use and implement at action of matters of concern in PFD reports”.
There is a much more strategic recommendation (15) that the Ministerial Board on Deaths in Custody should sent PFD reports to the House of Commons Justice, Health and Home Affairs Select Committees which should consideration taking evidence on significant themes.
RESEARCH
The report authors conducted some sampling of 20 PFD reports which were selected to give a representative sample of deaths in various kinds of custody setting – arrest, prison and detention under the Mental Health Act. It was from this sampling the view was formed about “repeat matters of concern going unleaded” (p9). The death of Leon Briggs (Bedfordshire, 2013) was highlighted where the Coroner “identified that more people could die due to the still-insufficient national guidance for police and ambulance services in responding to medical emergencies.”
There is a research based debate to be had about PFD notices, for the reasons set out in the report. The notices themselves are about the coroner flagging “matters of concern” but the documents don’t always outline the background reasons for those concerns – the quality of notices and the detail they contain is variable (see p14 onwards) and I’ve often read them and had a list of questions I can’t answer, to understand what the coroner might be getting at. For this reason, publishing a record of inquest may assist in understanding that detail.
It is also worth noting that report highlights that even Coroners themselves don’t always have access to a searchable database of PFD notices, to allow them to see whether the matters of concern they may be inclined to raise have been raised before, either in that area to the same organisation or in other areas to other police forces or mental health trusts. I note, for example, the PFD notice after the death of Mr Nigel Abbott in Birmingham found the coroner listing many other examples of deaths in the city which had occurred for reasons also connected to the lack of available inpatient mental health beds.
LEARNING
Chapter Four (p22) is the big one, for me. It discusses the importance of learning and follow-up on these important notices. Starting with the legal point that no Coroners have legal powers to ensure agencies either respond to the notice or implement the recommendations. The report notices coroners often find their “matters of concern” have not been corrected, sometimes after similar deaths occur (as in the beds problem in Birmingham). Families expressed concern to the report authors about this, hence giving rise to the allegation the PFD process is “just a paper exercise”.
“Why might PFD reports not have the impact expected” … various reasons, but ultimately there’s not much research. PFDs often focus on operational resources, training for operational staff and so on. Less often do they flag the more strategic leadership and resouring issues which created conditions within which staff have the chance to mitigate outcomes, whilst properly trained and led. There are exceptions to this: such as the Birmigham coroner’s PFD highlighting a large number of broadly similar background factors prior to homicide and suicides.
And what is a little missing from this report and PFDs as well, is the cross-agency nature of some of the more controversial deaths in state custody we’ve seen. In his 2016 book Deaths After Police Contact, David Baker from University of Liverpool wrote about the complex health backgrounds which often precede police contact, such as the deaths of Sean Rigg (but we could also add to that Kinglsey Burrell, Seni Lewis and many others). The partnership implications of work that is necessary to mitigate the risk of deaths in state custody needs more emphasis, in this report and research more generally.
For anyone interested in this subject, I recommend reading the whole report.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2023
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 