13. Memorandum from Inquest
INQUEST is the only non-governmental organisation
in England and Wales that works directly with the families and
friends of those who die in custody to provide an independent
free legal and advice service to bereaved people on inquest procedures
and their rights in the Coroner's Court. We provide specialist
advice to lawyers, the bereaved, advice agencies, policy makers,
the media and the general public on contentious deaths and their
investigation. We also monitor deaths in custody where such information
is publicly available and identify trends and patterns arising.
INQUEST is unique in working directly with the
families of those who die in all forms of state custodyin
which we include deaths in prison, young offender institutions,
immigration detention centres, police custody or while being detained
by police or following pursuit, and those detained under the Mental
Health Act as they involve people whose liberty has been taken
We have accrued a unique and expert body of
knowledge on issues relating to deaths in custody and seek to
utilise this towards the goal of proper post-death investigation
and the prevention of custodial deaths. INQUEST has been at the
forefront of working alongside bereaved people to bring the circumstances
of the deaths into the public domain and under public scrutiny
and to hold the relevant authorities to account. We have reported
our concerns about custodial deaths and their investigation at
a national and international level.
We were also consultants to the Liberty project on deaths in police
custody and many of our recommendations were endorsed in their
There have been a significant number of high
profile deaths in custody that have raised public and parliamentary
disquiet. This legacy needs to be fully understood if we are to
move forward and ensure that the custodians are truly accountable
to the community they serve.
INQUEST has supported families' calls for a
full public inquiry into the issues raised by deaths in custody
for many years but these have received a negative response from
government. INQUEST has been frustrated by the failure to learn
the lessons from deaths occurring in different custodial settings
and the lack of joined up learning between agencies. In our view
this has resulted in more deaths occurring because of the failure
to approach this serious human rights issue in a holistic way.
Many of issues arising from deaths in custody need to be fed into
the wider agenda for social inclusion of government, local authorities
and voluntary sector. Many of the deaths which occur are part
of a pattern which impact on policies on combating racism, drug
and alcohol use, homelessness, mental health, crime prevention
To this end we recommend the setting up of a
Standing Commission on Custodial Deaths which would bring together
the experiences from the separate investigation bodies set up
to deal with the police, prisons, hospital deaths and the others.
Such an over-arching body could identify key issues and problems
arising out of the investigation and inquest process following
deaths and it would monitor the outcomes and progress of any recommendations.
It could also look at serious incidents of self-harm or near deaths
in custody where there is a need to review and identify any lessons.
Arising from this it would develop policy and research, disseminate
findings where appropriate and encourage collaborative working.
Lessons learnt in one institution could be promoted in the other
institutions, best practice could be promoted and new policies
designed to prevent deaths could be drafted and implemented across
all the institutions. It would play a key role in the promotion
of a culture of human rights in regard to the protection of people
It should also have powers to hold a wider inquiry
where it sees a consistent pattern of deaths. Such an inquiry
could give voice to and a platform for examination of those broader
thematic issues and those issues of democratic accountability,
democratic control and redress over systemic management failings
that fall outside the scope of the inquest. One of its functions
would also be to lay the past to rest and assisting the process
of effecting real and meaningful change.
This submission details current concerns arising
from our casework and monitoring of the investigation and inquest
process following deaths in custody. In the last ten years 1824
men, women and children have died in police and prison custody.
Many of these deaths raise concerns about inhuman and degrading
treatment, systemic failings and the unlawful use and abuse of
force. Since 1990 there have been nine unlawful killing verdicts
returned at inquests into these deaths and no successful prosecution
of any police or prison officer.
We draw the committee's attention to:
The increasing number of deaths in
police and prison custodya disturbing number raising concerns
about inhuman and degrading treatment;
deaths due to alleged drunkenness
or drug intoxication;
deaths involving poor medical care;
police pursuitsan increasing
percentage of police related deaths are following pursuits or
otherwise involving police vehicles;
the lack of accountability and transparency
in the investigation process;
the disproportionate number of deaths
of black people following the use of force;
the poor treatment of the mentally
ill in custody and inadequate medical care;
the lack of central collection and
collation of information on deaths of detained patients and monitoring
of the issues arising from inquests;
the poor treatment of bereaved families
following a death in custody/psychiatric care;
the inadequacy of the current investigation
and inquest process;
the inequality of arms of the family
compared to the state ;
the failure of the state to learn
from previous deaths and to ensure inter-agency communication
and learning; and
the lack of accountability of state
An independent public inquiry should
be set up to look at all the issues relating to deaths in custody
in an open, systematic and inclusive way. We have been frustrated
at the government's piecemeal approach to the complex issues of
deaths in custody and their investigation and the lack of "joined
up government" on this issue.
The need to establish a Standing
Commission on Custodial Deaths.
2. DEATHS IN
2.a Issues arising from prison deaths:
institutionalised attitudes towards
prisoners that cause an indifference to pain and distress and
help to prevent learning;
young people in deep distress described
as manipulative trouble makers;
a disturbing number of self-inflicted
deaths in prison of people who had a known previous psychiatric
the rise in the number of youth deaths
and in particular of remand prisoners, the need for an understanding
of the needs of young people;
a significant rise in the number
of deaths of women in custody;
the link between prison deaths and
inadequate or inappropriate health care;
the increasing number of drug related
self-inflicted deaths in prison of prisoners who are not given
treatment and support for drug withdrawal;
the stereotyping of black people
with mental health problems;
the use of prison as a "place
of safety" for those with serious mental health problems;
the number of self-inflicted deaths
which occur within Health Care Centres;
the need for a reduction in the use
of imprisonment rather than treatment of vulnerable people, for
whom prison is the worst place to be. Prisoners with mental health
problems are often a risk more to themselves than to others as
the increasing catalogue of self-inflicted deaths in prison reveals;
inadequate policies to deal with
there has been a pattern of failure
to acknowledge self harming behaviour as an expression of distress
which has often led to such behaviour being treated as a discipline
problem and for clearly distressed people to be placed in segregation
rather than receiving appropriate care;
continuing problems with cell design,
access to ligature points; and
the need for diversion schemes for
those suffering from mental health problems, drugs and alcohol
2.b Women's deaths
There is a crisis in women's prisons highlighted
by the increasing number of deaths and incidents of self-harm
and the numbers of women prisoners with mental health and or drug
and alcohol problems being sent to prison. This year 14 women
have died in prison custody, the highest number ever recorded.
12 out of the 14 have died as a result of hanging themselves,
two having taken an overdose of medication.
In response to public concern about the situation
at Styal prison where six women died during an eight month period
the Prison Minister announced an investigation by the Prison Ombudsman
into the death of Julie Walsh. We were concerned at the narrow
remit of the review and that it was not reinvestigating the other
deaths. There was also concern that families of the other women
who died were being asked for their views without having had disclosure
of the investigation reports into their relative's death. INQUEST
feels that this investigation was a missed opportunity to set
up a wide-ranging independent public inquiry that examined all
of the recent deaths, any institutional and systemic failings
and most importantly involved bereaved families and women prisoners
INQUEST put in a submission to the investigation
about our concerns the treatment of bereaved families following
deaths in prison. Our contact with some of the families affected
reveal concerns about communication with the Ombudsman's office
about the timing and publication of the report. Our concern is
also with his use of Prison Service investigators to conduct his
2.c Deaths of children and young people
INQUEST has prioritised work on the deaths of
young people and children in custody since 1990, when we advised
and supported the family of Philip Knight, a 15 year old boy who
took his own life in Swansea prison. We have been frustrated by
the large number of cases that have raised similar issues and
the apparent failure of the Prison Service to learn the lessons.
We believe that for many young people prison
is inappropriate and that their experience of imprisonment has
directly contributed to their death.
Between January 1990 and December 2003 there
have been 177 self-inflicted deaths of young people in prison
(21 and under). There have been a total of 947 self-inflicted
deaths in prison. These figures are situated in the context of
21,760 reported incidents of self-harm in prison between 1998
and April 2002. Although these are not broken down in detail it
is recognised widely that self-harm amongst young prisoners, particularly
women, is an urgent problem.
We would like to draw the committee's attention
to the case of Joseph Scholes which is illustrative of the concerns
these deaths raise about the way in which the criminal justice
deals with children. It also reveals the inadequacy of the current
inquest system to deal with the complexity of issues by these
cases that engage Article 2 of the Human Rights Act.
Joseph was a deeply disturbed boy who had disclosed
a history of alleged sexual abuse from an early age. On 24 March
2002 he hanged himself in his cell at Stoke Heath Young Offender
Institution in Shropshire. His death occurred just nine days into
his two-year sentence for street robbery.
Joseph's death and other tragedies like it,
raise serious issues about the ability of the present system to
cope with society's most vulnerable young people and to provide
them with a safe as well as a secure environment. The question
arises as to how best to identify any systemic failings that do
exist and how future tragedies can be avoided.
The case for a public inquiry rather than an inquest
INQUEST, Nacro and Yvonne Scholes, Joseph's
mother recently launched
a call for a public inquiry into his death.
The narrative of Joseph's life is grim reading
and reveals a catalogue of failures by state agencies to provide
appropriate care and help to an exceedingly vulnerable child.
Joseph's death raises a number of wider questions
about the treatment and care of children in the criminal justice
system and the accountability of those agencies responsible, in
particular the Youth Justice Board, the Prison Service and Social
Services Departments. It asks questions of society and how it
should respond when children show clear signs of being disturbed
and in need of professional intervention. It raises questions
about how agencies and individuals could have intervened in Joseph's
case and how we can ensure that we have better systems and better
practice in the future.
These are issues of policy, which no inquesthowever
well conductedcan cover in the way a public inquiry could.
A public inquiry into a case like Joseph's would be able to examine
the fundamental flaws in our system for dealing with children
who break the lawflaws which have led to 25 children aged
15 to 17 taking their own lives in custody since 1990.
The current inquest system is incapable of dealing
with the systemic issues highlighted in cases such as Joseph's
and consequently fails victims, their families and the wider public
interest in seeking to ensure that lessons are learnt to avoid
future fatalities. Given the pattern of deaths of children in
prison, the number of different state agencies involved in Joseph's
care, the systemic and wide-ranging issues involved, and the narrow
confines of the coronial system, any inquest into Joseph's death
will not be able to fulfil the state's obligations under Article
2 incorporated by the Human Rights Act 1998 to identify faults
in the system that might have led or contributed to the death
and to enable steps to be taken to prevent the recurrence of such
deaths in the future.
Six months before Joseph died 16 year old Kevin
Jacobs hung himself from the bars of his cell. He too had been
identified by prison staff, social workers and doctors exceptionally
vulnerable disturbed and "at risk" young boy. The inquest
jury returned a verdict of "system neglect" fining "gross
deficiencies within the system and a failure to provide consistent
and safe accommodation."
3.a The General Issues
INQUEST has worked with many of the families
of those who have died on the most significant and controversial
deaths in all forms of custody over the past two decades in particular
those involving the use of force.
The majority of these involve the police.
INQUEST's work in this area reveals serious
shortcomings in the existing mechanisms of legal and democratic
accountability, and the consequent impact in particular on community
relations has been profound, resulting in a lack of public confidence
in the current system. Until recently complacency and inaction
have characterised the response from government agencies during
the last two decades to these deaths. This indicates a failure
and/or unwillingness to ensure that systems are in place to learn
the lessons to prevent further deaths and ensure accountability
of agencies of the state.
For two decades we have documented our concerns
about deaths where the use of restraint by state agents has either
caused or played a significant contributory factor in the death
of the deceased. Casework
in police prison and psychiatric custody has revealed concerns
about the excessive use of force generally including the use of
CS spray, US style batons, firearms, strip cells and medication
as well as the use of dangerous "control and restraint"
methods such as body belts, "neck holds, and other restraint
techniques resulting in the inhibition of the respiratory system,
asphyxia and death."
The recent inquest
into the death of Roger Sylvester highlighted the issue of the
police using dangerous methods of restraint despite a pattern
of previous deaths.
A recurrent theme in these deaths is a quick
resort to the use of force in general and restraint in particular
among our detaining authoritieseven where there are available
and practical alternatives, which are not considered. In theory
restraint is supposed to be deployed as a means of last resort
but is not translated into practice. Regulations governing the
use of restraint as a means of last resort appear to remain enshrined
only on paper.
While the number of deaths involving the use
of force are a small minority of all deaths in custody they have
been the most controversial because of what they have revealed
about the excessive use of force by functionaries of the state.
There is no central collation of statistical
or other information on restraint related deathswe are
dependent on the individual agencies for that information where
it is made available, and our own monitoring.
In 2002 and 2003 our casework on police custody
related deaths has seen a disturbing increase in the number of
restraint related deaths particularly on those with mental health
3.b Particular problems with the criminal
justice and inquest system in these deaths
It is extremely rare for there to be a prosecution
after a death in custody even where there has been an inquest
verdict of unlawful killing.
Despite a pattern of cases where inquest juries
have rejected the official version of events and found overwhelming
evidence of unlawful use of force and neglect, no police or prison
officer or nurse has been held responsible either at an individual
level or at a senior management level for the institutional and
systemic failures to improve training and other policies.
Our monitoring of the cases has revealed an
institutionalised unwillingness and reluctance to approach these
deaths as potential homicides. This infects the whole process
from the investigation carried out by the police through to the
considerations by the Crown Prosecution Service. This serves only
to encourage a culture of impunity and sends out a clear message
to police and prison officers and other detaining agents that
these deaths can occur as a result of their acts or omissions
and they will not be called to account. The perception is created
that state agents are above the law. This is one of the most contentious
issues in relation to the approach of the criminal justice system
in relation to all deaths in custody.
Our casework suggests that when the use of certain
kinds of violence is embedded in the working culture of any organisation
(whether a hospital or the police) it isn't easily eradicated
by directives from above. Where there exist no real sanctions
for those who abuse restraint and force, it is easy to see how
those individuals working in detaining authorities are allowed
to feel that they can act with impunity. The bottom line therefore
relates essentially to the means by which the use of restraint
is regulated and the extent to which such regulation and its implementation
is open to public scrutiny as a basic safeguard against the abuse
There are limited opportunities for the public
scrutiny of the abuse of restraint and force in our custodial
institutions. Within the agencies involved there exist internal
investigative and disciplinary processes, which by their very
definition are not open to public scrutiny. Guidelines/manuals
on the use of restraint have been shrouded in secrecy and not
made available. In the absence of criminal proceedings against
those responsible for such abuse, we are left with the inquest
with all its limitations as the only forum at which the ensuing
deaths can be subjected to any semblance of public scrutiny.
We address some of the problems of the inquest
system below and these are all the more apparent in dealing with
these particularly disturbing deaths.
3.c Racism and stereotyping
Since 1990 INQUEST's monitoring has revealed
how a disproportionate number of black people and those from minority
ethnic groups have died as a result of restraint or serious medical
neglect. It is the emergence of statistical information backed
by factual accounts about the circumstances of the death that
has been crucial to understanding the influence of institutional
racism on the treatment of black people in custody. Another group
over represented are the mentally ill where "negative imagery"
once again informs their treatmentthe stereotype of the
mentally ill as "mad", "bad" and "dangerous".
These issues have been raised consistently by
INQUEST with the United Nations Committee on the Elimination of
Racial Discrimination who have commented on their dissatisfaction
with the current methods for investigating the deaths. It was
also touched upon in the Lawrence Inquiry report. This pattern
of deaths in custody feeds the perception and reality of racism
within the police and prison service and within the NHS.
Cases have revealed a use of violence on some
occasions that is greatly disproportionate to the risks posed
involving black and Irish people and the mentally ill, raising
questions about the attitudes and assumptions of some state officials
and pre-conceived ideas about the propensity to violence of particular
groups of people.
There has been considerable public anger particularly
amongst the black and Irish communities about what some of these
cases have revealed about the unlawful and excessive use of force
used against black and minority groups. Frequently at inquests
there is an attempt to demonise the person who has died and reference
made to their "superhuman" strength, and their "animalistic"
The disproportionate number of black deaths
in custody following the use of force was an issue that the government
was slow to acknowledge despite the fact that INQUEST were documenting
this issue at a national and international level.
The Home Office Bulletin "Deaths during
or following police contact 2002-03 published on 20 November 2003
highlighted the rise in the number of deaths of people from minority
ethnic communities. In response to this the Government has announced
that it has commissioned research from the PCA in an attempt to
discover any common factors underlying these deaths. It is a matter
of concern that their response to this situation is to seek research
from a discredited organisation in who the public have little
or no confidence in given their history of involvement in a number
of high profile black deaths in custody. INQUEST has not been
contacted as part of this research.
3.d The failures to learn the lessons
These deaths show a systemic failure to learn
lessons: to review, revise and implement policies, instigate new
training, to share and disseminate information and guidance across
different state agencies.
Evidence of dangerous practice and culture has
emerged but the lessons to be learned have not been applied to
the range of organisations that are increasingly involved in restraining
police and prison officers and those
working in psychiatric custody;
private security firms detaining
and those working in care homes for
children, people with learning disabilities and older people.
In the majority of restraint-related deaths
coroners have reiterated their concerns about restraint training
and made recommendations but there is no mechanism for monitoring
such recommendations and their communication and subsequent implementation
across relevant Government departments.
In our view this failure to act and ensure
inter-agency communication and collaboration in terms of policy
and practice around restraint has resulted in more deaths and
3.e Deaths of detained patients
The deaths of detained patients remain shrouded
in secrecy and are not in the public domain to the extent as those
that occur in police and prison custody.
Of particular concern is the failure of government
or any of its arms length bodies to collate and publish annual
statistical information about deaths of detained patients. The
existing internal systems for examining and reporting these deaths
are so poor that we believe some contentious deaths could escape
any public scrutiny.
And in relation to the inquest system there is no requirement
for the coroner to sit with a jurya matter that must be
addressed in any forthcoming reform of the inquest system.
INQUEST has been unable to take up the issue
of the deaths of detained patients in the same way that is has
worked consistently on the deaths of people in other forms of
custody. We believe that it has been due to the relentless pressure
we have applied in those cases that some change has happened in
these settings. This is impossible when even access to information
about who has died and in what circumstances is not available.
3.f What does INQUEST's work reveal about
deaths involving use of force?
The need for independent investigations
into deaths following the use of force. All deaths should be treated
as potential homicides until proven otherwise.
Police related deaths are not being
treated with the seriousness they deserve in terms of the investigation
processthe Police Complaints Authority are continuing to
sanction the same police force investigating itself even in cases
where there are clear questions about the possible abuse of force.
Very few members pass on our details to families. Families frequently
complain about their conduct and that they appear to be a mouthpiece
for the police. Families have also complained that Family Liaison
Officers have been actively discouraged families from contacting
INQUEST or from seeking legal advice and representation.
Questions about inappropriate restraint,
racist treatment, and lack of training and awareness and the failure
to review and revise practices in light of deaths.
Poor implementation, understanding
and co-ordination of restraint training, and a lack of joined
up thinking across government departments, made worse by the constant
introduction of new theories that dilute the importance of training
of the dangers of methods of restraint.
There should be national training
standards across different agencies and the establishment of an
inter-agency group to share best practice and working with the
Health and Safety Executive, to set up and monitor standards for
the validation of training modules and courses;
The persisting ignorance about restraint
related health risksfailure to keep watch on the physical
well being of a restrained person has played a major part in many
The lack of centrally collected and
publicly reported information on the deaths of detained patientsfollowing
pressure on the police and prison service by INQUEST details are
now provided on all deaths in police and prison custody including
racial/ethnic group. This should happen as a matter of course.
Cases have revealed a use of violence
disproportionate to the risks posed to officer/nurse, especially
involving black people and the mentally ill raising questions
about the attitudes and assumptions held by some state officials
and systemic and persistent deficiencies in police and prison
officer practices. Training must include an understanding of why
violence occurs and how to deflect it and use of alternative,
non-aggressive techniques rather than the ready resort to the
use of force.
The majority of inquests have seen
coroners recommendations but there is no mechanism to monitor
recommendations made by inquests and inquiries and their communication
and subsequent implementation across relevant government departments.
Custodians have a difficult and sometimes
dangerous job to do, to do their job however they must have the
confidence of those they serve, to earn and maintain that confidence
there must be a system of accountability that is open and transparent.
There needs to be an urgent inquiry
into the use of restraint across different state agencies.
4. THE INQUEST
INQUEST has always argued that the right to
an inquest is fundamental but that the current inquest system
is failing particularly in relation to deaths that involve questions
of state and corporate accountability.
There are severe shortcomings in the current
systems for investigating and providing remedies after deaths
in custody. These shortcomings violate Article 2 of the European
Convention on Human Rights which enshrines the right to and which
places a positive duty on the state to secure life. Investigations
of deaths in custody are secretive, slow and not independent.
The relatives of the deceased are too often excluded and marginalised.
To them, the investigation can often appear less a search for
truth than an attempt to avoid blame, frustrate disclosure, restrict
the remit of the investigation and demonise the deceased.
We gave a detailed submission to the Home Office
Fundamental Review of Coroner Services
detailing our concerns about the investigation and inquest system
based on 21 years of advising bereaved families, monitoring post
death investigations and attending inquests around the country.
"Any new system [of investigation] needs
to operate within a framework that ensures openness, accountability,
compatibility with the Human Rights Act and sensitivity to bereaved
people and the public. To establish such a framework there needs
to be clear national protocols for all aspects of post-death investigation.
Those protocols need to enshrine clearly defined mechanisms of
accountability, minimum levels of service delivery and a system
of sanctions where practice falls below acceptable standards.
The protocols need to set out clearly the rationale for each step
that is taken, in a manner that is understood by professionals,
bereaved people and the public. Above all it needs to be a system
that balances the needs of the State with those of bereaved people
and ensures that all participants have an equality of resources
and information. Whilst the process will be painful for bereaved
people it will be more bearable if it is seen to have legitimacy
and meaningful outcomes."
Public campaigns pursued by bereaved families
following controversial deaths in custody and following major
disasters have focused attention on the investigation process
following contentious deaths in custody and the inadequacy of
the coroners court as a forum for the examination of deaths where
the state is suspected of having some responsibility. INQUEST
monitoring has shown how the state uses the inquest and not the
criminal prosecution and trial for the public examination of these
deaths. These factors have serious consequences for families faced
with an unexpected or violent death.
"The narrow focus of the inquiry puts artificial
and invidious limits on the scope and style of conduct of the
Coroner's inquiry, which often exclude from the inquest the issues
of greatest concern to the family. The inquest is usually the
only investigation of death to which a family has access. Importantly,
for the public interest and democratic accountability it is the
only public forum in which contentious deaths will be subject
to scrutiny. Inquests are too often at risk, particularly in the
absence of legal representation for the family, of being opportunities
for official and sanitised versions of deaths to be given judicial
approvalrather than being an opportunity for the family
to contest the evidence presented, to discover the truth and full
circumstances surrounding the death of their loved one."
Too often families are left isolated from the
investigation process. They are unable to access the investigators
let alone the actual investigation. Frequently families are contacted
immediately after the death and asked to co-operate or participate
in the investigation of their loved one. At this very early stage
they will be going through a whole myriad of emotions. Grieving
for their loved one, angry frustrated at the level of information
forthcoming. There may also be feelings of guilt and of course
When an investigator who is viewed as part of
the Prison or Police Service then asks at this stage of the bereavement
process for the family to be involved in the investigation it
is not surprising that families are unwilling or more likely,
are unable to get involved. This is before they have had chance
to clarify in their mind what the issues they feel are relevant
and when they are in no mental state to answer fully or accurately.
In our view for a family to properly participate in any investigation
they need time and space and often support from a third party
such as someone from INQUEST or a solicitor/advisor. Their role
can be very important in determining the terms of reference and
scope of the investigation. Again if they were informed from the
outset that they could participate in the investigation with the
assistance of a third party and have a say in the terms of reference
it might go someway to reassuring them that the death is being
taken seriously. Clear issues of sensitivity arise from such interviews.
Irrespective of whether or not a family decides to have full participation
in the process they should still be kept informed of the progress
of the investigation. INQUEST believes that more work needs to
be done in this area and that we have an important role to play
All the investigators into deaths in prison
are currently employees of the Prison Service. These investigators
have often been unable to establish a relationship with families
who are very often not confident in the way a death is being investigated
because it is not seen as independent of the prison service. This
of course is multi-factorial but issues of impartiality are paramount.
A clear need for independent investigators is required and well
documented in previous submissions made by INQUEST. In the recent
death at HMP Styal the Prison Ombudsman was asked to investigate.
However from the contact we have had with some of the families
affected, it has not been clear to them that the PPO is independent
from the Prison Service. This needs to be made more explicit.
There may well be a need to have prison employees involved in
the investigation but the need to demonstrate independence is
Length of an investigation
It is our experience that investigations into
police and prison deaths are not generally released to the family
until there is a date for an inquest. The inquest may not be held
for 612 months, sometimes longer.
In a recent case involving a restraint related
death in police custody the family was informed that although
the inquest was unlikely to be heard for at least a year, possibly
longer it was unlikely that they would receive disclosure until
28 days before the inquest. This is in line with the pre-inquest
disclosure guidance but in view is completely unreasonable. We
do not see why the investigation reports are not disclosed immediately
on completion. This would also allow the family/family lawyer
to raise matters that they do not feel have been addressed in
the investigation (see paragraph below on disclosure of information).
Disclosure is not provided as of right, not
provided early enough and is too obstructive and allows material
to be kept secret. In our experience disclosure is something the
family/family lawyer has to fight for. The introduction of the
voluntary protocol in April 1999 has brought some clarity to the
process of disclosure and was welcomed but many problems still
remain, particularly in the most contentious cases. Early disclosure
of custody-generated documents is vital if the family and their
representatives are to have effective and constructive participation
in the investigation.
Findings and recommendations arising from investigations
It has often been lawyers instructed by families
in pushing the boundaries of the inquest system who have helped
to expose through their legal representation systemic and practice
problems that have contributed to deaths. Indeed many of the changes
to police/prison training and guidance or public awareness of
health and safety issues have been as a direct result of families
representation at inquests and our lobbying work thereafter for
change and for lessons to be learnt.
There is unlimited public funding for experienced
and quality lawyers to represent the Police while union or association
funding is available for the police officers, or medical officers.
INQUEST believes that where such a death occurs there should be
an automatic right to public funding for legal representation
without means testing. Although there has been some progress and
all deaths in custody (though not involving deaths following police
pursuits) are now recognised as coming within the scope of the
funding code. Relatives of the deceased whom the law recognises
have a legitimate interest cannot afford to take up that representation
unless they are eligible for legal aid which effectively excludes
a lot of low and middle income families. The Legal Services Commission
has taken a very restrictive interpretation of eligibility.
The recent decision of Khan will improve the
situation as it has resulted in a new statutory instrument
that gives the power to the Legal Services Commission to ask the
Secretary of State at the Department of Constitutional Affairs
to waive financial eligibility criteria in requests for funding
for representation in inquest cases that engage Article 2.
The narrow remit of the inquest and its dependence
on the police/prison investigation prohibits exploration of the
wider policy issues or indeed any mention whatsoever of any other
death than the one currently being investigated. Indeed the High
Court in the Sacker case and the House of Lords in Amin
have recently questioned whether the present coronial system is
an appropriate means for looking into cases that raise wider issues
Coroners have very wide discretionary powers
to determine the scope of each inquest and although there is case
law specific to deaths in custody that requires a "full and
fearless investigation", that is open to wide interpretation.
There is great variation in their practice and similar deaths
in different parts of the country may be treated in very different
The majority of information that has entered
the public domain about deaths in custody has arisen only because
of the deceased's family and friends full participation in the
inquest proceedings facilitated by their legal representation.
It is very rare for a coroner in the absence of legal representation
on behalf of the deceased to conduct the kind of searching questions
that occur when a family is represented. Many coroners are ill-equipped
and are unaware of what is happening nationally to clean an understanding
of broader policy issues surrounding custody type deaths or have
not been provided with all the relevant disclosure by the police
because they have not known what to request. The issue of resources
is also a serious problem for coroners. This is very relevant
when considering the inquest is the only public forum in which
these deaths are subjected to any scrutiny and where systemic
failings can be exposed. We are aware that there are custody deaths
that have not been properly scrutinised because families did not
have information and the resources or where the deceased had no
Our experience of such inquests is that lawyers
representing custodial institutions are consistently instructed
to take a defensive approach to the proceedings, trying to shroud
what has happened or to attack the character of the deceased rather
than assisting the court in the exercise of an impartial scrutiny
of the death. In addition the approach to the inquest from the
authorities as a damage limitation exercise means that there has
been a reluctance to learn from these investigations.
The recent inquest into the death of Roger Sylvester
gives a good example. The lawyer acting on behalf of the Metropolitan
Commissioner paid for out of the taxpayers purse via the Metropolitan
Police Authority did not take a neutral role but launched an attack
on the deceased and the lawyers and family campaign accusing us
of having a political agenda.
We also see this post death where misleading,
inaccurate information is placed into the public domain by police
about the death in an attempt to demonise the deceased, blame
them for their own death and deflect attention away from the conduct
of the police.
The limited ambit of investigations, ineffective
inquiries and the failure to prosecute those responsible has all
been issues for bereaved families. They have also increasingly
become an issuein law both in the ECHR and in the domestic courts.
Where a citizen dies or suffers ill treatment
in custody, the reaction of the State raises very serious questions
about the protection of human rights. As a public authority the
Police/prison service/has to comply with the Human Rights Act
and all courts and tribunals including the coroner's court are
also under a duty to ensure that convention rights are protected.
There is already in existence case law about
the importance of a full inquiry into deaths in custody and indeed
under the Coroners Act there is a requirement for an inquest with
a jury to sit on such deaths. The problem is that under the Coroners
Act 1988 the inquest has a very narrow remit and is manifestly
not a public inquiry; it is concerned primarily with establishing
the medical cause of death, how the person died, by what means
and not in what broader circumstances.
The most significant recent development in coronial
law has to be the implementation of the Human Rights Act and the
direct incorporation of Article 2 (the right to protect and safeguard
life) into domestic law. The obligation on the state to protect
the right to life requires the state taking appropriate measures
to protect life, to investigate deaths and ill treatment in custody
thoroughly and to prosecute where there is sufficient evidence
to justify proceedings.
The obligation to take positive steps to protect
life also requires some sort of investigation where death has
occurred in a way, which engages Article 2 and 3 of the Convention
because any fault in the system for protecting the right to life
may well lead to further deaths (McCann v UK) and the lack of
an effective investigation will in itself constitute a violation
of Article 2.
The decision of the House of Lords on 16 October
this year in the case of the SSHD ex-parte Amin, establishes once
and for all consistent minimum standards for the state's duty
to investigate deaths in custody.
The case arises out of the murder in a cell
at Feltham YOI of Zahid Mubarek by his cellmate Robert Stewart.
Despite a wealth of evidence warning of the dangers posed by Stewart,
from his previous violent conduct in custody, his volatile mental
state and racism they had been allocated to share a cell for 6
weeks before his murder. There was a complex history of investigations
by the police, the Prison Service and the CRE, However no public
hearings had been held and no opportunity arouse for the significant
involvement of the next of kin.
The House of Lords ruled that whichever form
the investigation takes there are minimum standards, which must
be met as, set out in Jordan v UK
and Edwards v UK. The Court concluded in Jordan that there were
five essential requirements of the investigatory obligation: independence,
effectiveness, promptness and reasonable expedition, public scrutiny
and accessibility to the family of the deceased. The lack of an
investigation which embodies the requisite qualities will and
of itself constitute a violation of Article 2.
It ruled that such requirements apply with at
least equal force to a "state neglect" or omission case
(relevant to deaths in police custody) as to a state `lethal hands'
The approach to the House of Lords to the inquest
issue is instructive. The coroner's affidavit explained her exercise
of her discretion not to hold an inquest into this case (a discretion
coroners have where a criminal trial has taken place) She gave
detailed reasons why the resource and procedural restraints to
which coroners and inquests are subject make an inquest an unsuitable
vehicle for investigating publicly the issues raised by this case.
It was conceded for the family that in principle
an independent police investigation and an inquest are capable
of fulfilling the "Jordan" requirements and the state's
investigative obligations as established by McCann as to the adequacy
of the Gibraltar/SAS shootings inquest.
Many of INQUEST's concerns about the inquest
process were put forward for the family at the Amin hearing including:
inconsistency of disclosure of evidence to the family despite
the Home Office circular, inconsistency of funding, the narrow
boundaries to the jury's findings, coroners current restrictions
upon system neglect. The Amin judgement recognises these concerns
as legitimate and these comments are a vindication of our concerns
about the inadequacy of the current inquest system in relation
to contentious deaths in custody.
The Lords accepted the coroners reasoning both
as to the problem of resources and legal restriction and agreed
that many of the issues needing investigation `would be beyond
the scope of inquest. Lord Bingham refers to the Home Office review
of coroners recommendations indicating that if implemented they
would avoid such problems and adding that "no doubt they
are receiving urgent official attention." (our emphasis).
There is now strong recognition of the need
for more effective investigation than can be currently provided
by inquests. The issues raised about individual and system neglect
in the Amin although rare are sadly not unique. Until substantially
reformed there is strong judicial recognition for the need for
more effective investigations than can currently be provided by
inquests and provides an important incentive to accelerate the
programme for inquest reform.
This legally significant case has been brought
about because of the courageous struggle by the family of the
deceased whose campaigning will contribute to the future protection
of vulnerable prisoners. Lord Bingham recognised this as one of
main purposes of the investigation and thereby humanely connected
the needs of the bereaved with the duties of the state. 
7. THE TREATMENT
Finally we would draw the Committee's attention
to the poor treatment of bereaved families following deaths in
custody. Despite a wider acknowledgement of the issues faced by
bereaved people discussed below this thinking has bypassed families
affected by deaths in custody.
In our submission to the Fundamental Review
of Coroner Services
"In our experience the nature of the circumstances
of many of the deaths on which we work inherently attracts prejudice
and strong feelings and the majority of families we work with
do not experience the system as compassionate. Families feel overwhelmingly
excluded, dissatisfied and let down by it as a process for establishing
the facts. The coroner's inquest has become an arena for some
of the most unsatisfactory rituals that follow a deathaccusations,
deceit, cover-up, legal chicanery, mystification; everything but
a simple and uncontroversial procedure to establish the facts.
There have been some important procedural changes
but little substantial systemic change. Some of the more recently
appointed coroners do have a different approach to their work
but like many institutions what is needed is a culture shift.
There are important developments taking place in the wake of the
Alder Hey scandal and the beginnings of a greater understanding
of the support needs of families following sudden and unnatural
death. However, we remain concerned that the mainstream provision
of bereavement support is delivered in the absence of evidence-based
research on the particular impact of bereavement and the inquest
process. It is also clear that those families who suffer the death
of a loved one in custody are not considered in any of the initiatives
taking place. There seems to be an institutional inability for
the authorities to acknowledge that the need of a family whose
loved one has died in custody are just as acute as those of someone
who has lost a loved one following a death in hospital or a murder.
However most new bereavement initiatives do not appear to have
considered these families at all."
With custody related deaths the lack of support
and appropriate assistance is more acute with families feeling
doubly victimisedthey have suffered a death and because
of its nature they are treated as though they are criminals.
All deaths in custody involve an inquest so
the potential role of the Coroner's Service in guaranteeing informed
and effective access to appropriate bereavement intervention options
for bereaved families must therefore be a central concern in developing
a new system.
Finding out how someone has died is a fundamental
human right and an essential part of the bereavement process and
in coming to terms with the death. All of the families who have
sought our assistance have been motivated by a need to establish
the truth for their own peace of mind, and to prevent others going
through the same experience. Above all, they want an acknowledgement
of fault or responsibility where appropriate, an apology where
an apology is due, for justice to be seen to be done and for lessons
to be learnt.
Maximising the possibility for families and
friends to discover the truth is the guiding principle of INQUEST's
casework service. The family can have a real information deficit
after a death in custody. They have a very steep learning curve
to understand the various investigations that are initiated by
such a death. Some argue that the family should not be overloaded
with information. Access to proper information and advice is crucial
in ensuring that people are aware of their rights and it is the
responsibility of the State to ensure that this happens at the
earliest possible opportunity.
This should include information about access
to the body, post-mortems, organ retention, rights regarding disclosure,
the inquest process, and legal rights.
"The way families are informed of a death
and the treatment they receive from officialdom at this stage
can crucially set the tone for the way they are able to interact
with the process."
In our submission to the Prison Ombudsman on
the treatment of families we documented our concerns about the
poor treatment of families by many state agencies and the need
for families to receive clear, accessible and accurate information
about the circumstances of the death and where they can seek advice
and support. It is a matter of real concern that there is still
no mandatory requirement on the part of the police/prison service/NHS
to give out INQUEST's details and information leaflet. This happens
on an ad hoc basis only and is entirely dependent on the individual
with contact with the bereaved. Provision of our information would
at least give families the choice as to whether or not
they contact us. We have too many families contacting us at a
later stage in the process having been referred by friends/press
etc and who would have benefited from specialist advice and emotional
support much earlier.
A recent example of this is the mother of a
young woman who took her own life in Styal prison in November
2002. She was given no information about INQUEST from the Prison
Service or the Prisons Ombudsman when in contact with her as part
of their investigation into Styal.
The mother of the deceased found about us via
a small advice service in North Wales and contacted us for help.
We have been able to find her a solicitor to assist her with preparing
for the inquest which is yet to be heard and to refer her to a
family who have been through a similar experience for emotional
support. The result of the failure to refer the mother to us a
year ago is that she has been alone and unsupported.
|Oliver Pryce||Black||1990 Police
||1991 Prison||HMP PentonvilleLondon
||No||Yes ||Unlawful killing
|Leon Patterson||Black||1992 Police
||Manchester Police ||No
||Yes||Unlawful killing quashed; new inquest 1996 misadventure contributed to by neglect
|Joy Gardner ||Black||1993 Police/ Immigration officers
|Richard O'Brien||Irish||1994 Police
|Shiji Lapite||Black||1994 Police
||Metropolitan Police ||No
|Alton Manning ||Black||1995 Prison
||HMP Blakenhurst Kidderminster||No
|David Ewin||UK White||1995 Police shooting
||Metropolitan Police||Yeshung jury
|Ibrahima Sey||Black||1996 Police
||1998 Police||Humberside Police
charged with and acquitted of manslaughter
|James Ashley||UK White||1997 Police
|Roger Sylvester||Black||1999 Police
DEATHS IN PRISON CUSTODY 1993-2003
|Control & Restraint||0
BLACK DEATHS IN PRISON 1993-2003
| (Percentage) ||6%
| (Percentage) ||50%
| (Percentage) ||0%
|Control & Restraint||0
YOUTH DEATHS (21 AND UNDER) IN PRISON 1993-2003
| (Percentage) ||6%
JUVENILE DEATHS IN PRISON 1993-2003 (AGED 17 AND UNDER)
NB these figures are also included in the table of Youth deaths
DEATHS OF WOMEN IN PRISON 1993-2003
| (Percentage) ||2%
| (Percentage) ||50%
DEATHS IN POLICE CUSTODYALL FORCES 1993-2003
BLACK DEATHS IN POLICE CUSTODYALL FORCES 1993-2003
POLICE CUSTODY DEATHSRESTRAINT ISSUES RAISED 1993-2003
| (Percentage) ||6%
Source for all statistical information: INQUEST monitoring.
* Figures for Black deaths, Youth deaths, restraint-related deaths
and deaths of Women are all included in the relevant tables for
deaths in Prison and Police custody.
* All percentages refer to the proportion of the total number
of that classification of death in that year or total.
The Ashworth Inquiry 1992; United Nations Committee on the Elimination
of Racial Discrimination 1996 and 2000; Council of Europe Committee
on the Prevention of Torture 1997; Home Affairs Select Committee
on Police Complaints and Discipline 1997; United Nations Committee
Against Torture 1998; Inquiry into the death of Steven Lawrence
1998; Health Select Committee into Adverse Clinical Incidents
and Outcomes in Medical Care 1999; Health Select Committee Inquiry
into the Provision of Mental Health Services 2000; Attorney General's
review of the role of the Crown Prosecution Service in deaths
in custody 2002; Fundamental Review of Coroners' Services 2002;
Joint Committee on Human Rights-deaths in prison 2002; Independent
Inquiry into the death in psychiatric care of David Bennett 2003. Back
For statistical analysis see appendix 1. Back
See appendix 2. Back
Prison suicide of Joseph, 16, a phone thief who fell victim to
sentencing policy-Independent 12/11/03. Back
A child's death in custody-Call for a public inquiry-INQUEST and
NACRO Campaign Briefing-November 2003. Back
INQUEST press release 26 September 2002. Back
Forthcoming publication-Deaths in Custody following the use of
force-INQUEST 2004. Back
This means working closely with family members, very soon after
the death, referring them to appropriate lawyers, working with
the legal team, attending the inquest, raising the issues with
relevant agencies and government departments and with MPs and
other interested organisations. This gives us a unique body of
knowledge from which to comment on the deaths and the issues they
See INQUEST reports on the deaths of Denis Stevens, Alton
Manning, Kenneth Severin, Harry Stanley, Brian Douglas, Wayne
Douglas, Shiji Lapite, Glenn Howard, Roger Sylvester and Giles
September 2003. Back
See cases of Giles Freeman, Mikey Powell, Andrew Jordan. Back
INQUEST/Liberty/Bhatt Murphy submission to Attorney General review
of CPS decision making following deaths in custody-2002. Back
INQUEST written evidence to the Inquiry into the death of David
Bennett 2003. Back
How the inquest system fails bereaved people-INQUEST's submission
to the Fundamental Review of Coroner Services-Deborah Coles and
Helen Shaw-INQUEST 2002. Back
Coles and Shaw op cit. Back
Coles and Shaw op cit. Back
The Community Legal Service (Financial) (Amendment No. 2) Regulations
2003. Statutory Instrument 2003 No. 2838. Back
SSHD v Amin 16 October 2003. Back
See INQUEST Law Winter 2003 Article by Paddy O'Connor QC. Back
Jordan and ors v. UK (4 May 2001) ECHR. Back
O'Connor op cit. Back
Coles and Shaw op cit. Back
Coles and Shaw op cit. Back
Coles and Shaw op. cit. Back