New report calls for more effective learning from death in custody inquests

provided by: INQUEST
published: 1 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.

Download report here >